Journal of the Michigan State Medical Society

The Journal

of the

Michigan State Medical Society

Published Under the Direction
of the Council

Publication Committee
Wilfrid Haughey, M.D. (Chairman)

Otto O. Beck, M.D.

T. E. De Gurse
Roy C. Perkins, M.D.

C. E. Umphrey, M.D.

Roy Herbert Holmes, M.D.
Editor

L. Ferncdd Foster, M.D., Secretary and Business Manager
Wm. J. Bums, LL.B., Executive Secretary

VOLUME 40
19 4 1

TKe JOURNAL

of the Michigan State Medical Society

Issued Monthly Under the Direction of the Council
Volume 40 January, 1941 Number 1

e

Medical Societies and
Medical Progress

By Rufus Cole, M.D.
Mt. Kisco, New York

Rufus Cole, M.D.

B.S., University of Michigan ; M.D.,
Johns Hopkins University, 1899 ; Sc.D.,
University of Chicago. Member of the
Staff of the Johns Hopkins Medical
School and Hospital from 1899 to
1908. Member and Director of the Hos-
pital of the Rockefeller Institute for
Medical Research from 1908 to 1937.
During this period engaged in research
on problems relating to internal medi-
cine, especially infectious diseases. At
present. Member Emeritus, Rockefeller
Institute; Vice President New York
Academy of Medicine; Member, Na-
tional Academy of Sciences.

" As I STOP to take stock of my professional
life, I discover that besides collecting other
things I have been accumulating memberships in
medical societies. And now, having reached the
years supposed to offer opportunities for reflec-
tion, I have come to ask myself, how did medical
societies originate ; what were the reasons for
their foundation ; what have they accomplished ;
of what use are they?

So far as I can learn, there were no real medi-
cal societies of any significance, certainly not in
the English-speaking world, until the sixteenth
century, in the time of Henry VIII. At that
time, medicine as a profession did not exist in
England. There were a few physicians and trained
surgeons. But the care of the sick was chiefly
in the hands of the clericals, the apothecaries
and the barber surgeons. As members of the
clergy were forbidden by the canons of the

January, 1941

church to shed blood, they employed barbers to
carry out any necessary surgical measures. Drugs
and medicines were supplied by the apothecaries,
or storekeepers.

Royal College of Physicians

In Italy, however, the teaching of medicine was
already highly organized in a number of univer-
siUes. A young graduate of Oxford, Thomas
Linacre, went to Italy to imbibe something of the
new learning, of which the English universities
were just beginning to be faintly conscious. Be-
coming interested in medicine, probably through
his translation of medical manuscripts, he studied
and obtained a degree in medicine from the Uni-
versity of Padua. He returned to England, taught
at Oxford, and practiced medicine. Though he
was now a physician, he still remained a stu-
dent; he translated Galen, and during his entire
life he was a physician, scholar and grammarian
— one of our profession’s greatest humanists.

In time he became the physician of Henry
VHI. In the hope of improving the status of the
medical profession in England, Linacre in 1534
organized the Royal College of Physicians of
London and was made the first president. Al-
though the charter of the society stipulated
that henceforth no person except graduates of
Oxford and Cambridge should be "suffered” to
exercise or practice physic, until he had been
examined by the President and Elects of the
College, the College has never at any time at-
tempted to enforce that decree. It has never at-
tempted to enforce minimum requirements for
practice, but has established high standards to
which all those worthy of calling themselves
physicians would attempt to conform. Eor over
400 years, the possession of the degree of Mem-
ber or Eellow of the Royal College of Physicians
of London has been a guarantee that the holder

19

MEDICAL SOCIETIES AND MEDICAL PROGRESS— COLE

is a representative of all that is best in English
medicine.

The greatest of all the fellows was William
Harvey. It was in the anatomical theatre of the
College that he made his dissections, carried out
his experiments, gave lectures and demonstrated
his evidence for the most important physiological
discovery ever made, the circulation of the blood.
Harvey, like Linacre, was a great physician as
well as a scientist and scholar. He was the phy-
sician to Charles I and tutor to the two young
princes. In these days of the excitement of war,
it will do no harm for us to remember the story
of Harvey at the battle of Edgehill. Before the
battle, he waited with the two young princes in
a wide ditch at the top of the hill, and to while
away the time he took a book from his pocket
and read. When a bullet grazed the ground near
him he had to move, and when the battle really
began, he pocketed his book and became active
in assisting the wounded. Harvey built a library
for the College and furnished it with books, and
at his death left it his patrimonial estate, in order
to provide for three objects; first, to supply an
annual feast for the fellows ; second, to provide
for an annual oration in order to commemorate
the benefactors, to exhort the fellows and mem-
bers to study out the secrets of Nature by way
of experiment, and to urge them to live in love
and affection among themselves ; and third, to
provide for a librarian. Members of the medical
profession everywhere have a right to be very
proud that our societies originated with such
an institution as the College of Physicians.

Grocers Company and the Apothecaries

Medical societies have still another ancestor,
however. In the 15th and 16th centuries frater-
nities of artisans and tradesmen existed, and
were usually called mysteries or companies. One
of the most important of these was that of the
storekeepers, the Grocers Company. Belonging
to this were the apothecaries. They objected to
control by the untrained officials of the Grocers
Company, and, in 1617, those who wished to
secede were given independence through a royal
decree, and the Society of Apothecaries of Lon-
don was incorporated. The regular apothecaries
consulted the physicians. Those of you who are
familiar with The Gold Headed Cane will re-
member that it was there stated of the famous
Dr. Mead, that “in the forenoons, apothecaries
used to come to him, at Tom’s [a coffee house]

near Covent Garden, with written or verbal re-
ports of cases, for which he prescribed without
seeing the patient, and took half-guinea fees.”
Many apothecaries, however, did not bother to
consult a physician, and in 1703 an apothecary,
named Rose, was prosecuted for advising and
treating a patient without consultation. The final
decision by the courts was that apothecaries be
allowed to advise their patients as well as to
treat them. “This has been termed the Charter
of the general practitioner.” Ever since then the
society has given examinations to those desiring
to become members and to practice medicine.
Though all connection with trade has now been
severed, it still remains a society chiefly, if not
entirely, interested in the qualifications for gen-
eral practitioners, and during its long and honor-
able career it has consistently striven to elevate
these requirements.

Scientific Societies of the 17th Century

A third possible source from which our medi-
cal societies take origin is the scientific societies
of the 17th century, which developed almost si-
multaneously in Italy, France, Germany and Eng-
land. As during the fifteenth and early sixteenth
centuries occurred the great renaissance of learn-
ing and scholarship, so in the latter half of the
sixteenth and seventeenth centuries came the
dawn of modern science, the beginning of an era
in which we are now living. The desire to learn
more about natural phenomena possessed men’s
minds, observation and experiment took the place
of dialectics. It was an era for amateurs, men
with brilliant minds, who did not confine their
interests to narrow fields, and it is not surprising
that physicians took an important part in the
new movement. Acute interests, such as these
men possessed, were bound to draw them into
communication with one another, and so the sev-
enteenth century saw the origin of the great sci-
entific societies, some of which still exist. Francis
Bacon, in New Atlantis, described as Solomon’s
house, communities of men working with com-
mon scientific interests. But groups of scientists
existed in Italy even before Bacon’s imaginative
and romantic tale appeared.

Academia Natural Curiosoruni. — A young Ger-
man doctor from the small town of Schwein-
furth, in Bavaria, studied in Italy during
this period, and became interested in the
work of these groups and also read Francis Ba- j

20

Tour. M.S.M.S.

MEDICAL SOCIETIES AND MEDICAL PROGRESS— COLE

con’s New Atlantis. This young- doctor, Johann
Lorenz Bausch, went back to Schweinfurth and,
in association with three other doctors of the
town, organized a society in 1652 for the study
of scientific problems, and the publication of
their investigations. They called their society
Academia Naturae Curiosorum. The immediate
object was the advancement of medicine, but in-
terests soon spread to all natural phenomena.
This society still exists as the Deutsche Academie
der Naturforscher. It is the oldest scientific so-
ciety still in existence, and it is of interest that
it was started by four doctors at the close of
the Thirty Years’ War, when their country was
in ruins, and that its origin was inspired by the
romantic tale, N ew A tlantis.

Accademia del Cimento. — Doctors, although
they did not found it, played an important part
in the Accademia del Cimento, the Academy of
Experiment, organized in Florence in 1657, six
years after the German society. It lasted only
ten years, but the studies were of great signifi-
cance, and the members were important figures
in science. Among them were a number of phy-
sicians who played important roles in establishing
physiology and medicine on a scientific basis —
Borelli, Malpighi, Redi, Stensen, and others.

Royal Society of London. — This is true also
of the Royal Society of London, founded in 1662,
the most important of all the scientific societies
founded in the 17th century. This society was
the outcome of informal meetings held by a small
group at London and Oxford for the purpose of
discussing the new, or experimental philosophy.
Among the members of this group were a num-
ber of doctors. One of their rules was that any
Fellow of the Royal College of Physicians might
join. There has always been a considerable num-
ber of physicians in the Royal Society. Syden-
ham became a fellow in 1700. Sir Hans Sloan,
the famous physician. President of the College of
Physicians, and founder of the British Museum,
was the first physician to be made president.

Medical societies of later years have undoubt-
edly drawn their inspiration from the three
sources I have mentioned : The Royal College of
Physicians, The Society of Apothecaries and the
Scientific Societies organized in the 17th cen-
tury, the College, consecrated to learning, the
Society of Apothecaries, interested in the rela-
tions of practice to society, and the Scientific

Societies, devoted to experiment. None of the
later medical societies have been copied directly
from any of these earlier organizations, no one
of them has devoted itself exclusively to a single
one of the respective fields, but every one has
been interested in one or more of these domains,
some of them in all.

Medical Society of Edinburgh

In 1734, two hundred years after the founda-
tion of the College of Physicians, six fellow
medical students at the University of Edinburgh,
“the foremost in application and knowledge” . . .
met together “for their mutual instruction and
advancement in their studies.” Once a fortnight
a meeting was held at which a dissertation by
one of their members was discussed, and in 1737
this society, now composed of ten members, was
formally organized as the Medical Society of
Edinburgh. Conditions in Edinburgh at this time
were propitious for such an undertaking. There
was here a distinguished medical faculty, all the
members of which had studied in Leyden under
Boerhaave, and were carrying on clinical teach-
ing in the Royal Infirmary which had been
opened in 1729. This society, now the Royal Med-
ical Society of Edinburgh, has been devoted pri-
marily to fostering clinical and scientific medi-
cine. Admission is difficult and includes the pres-
entation of an original dissertation. For us this
society is of much interest, since it undoubtedly
influenced greatly the organization and develop-
ment of societies in this country.

Origin of American Societies

Two London physicians were also influential
in starting and moulding the character of our
societies. Dr. Samuel Fothergill, the great friend
of Franklin, and Dr. John Coakley Lettsom, who
carried on a wide correspondence with medical
men in this country, was made an honorary mem-
ber of most of the societies started here during
his lifetime and became an honorary member
and conservator of the New York Hospital. Dr.
Fothergill was one of the early members of the
Edinburgh Society and so was very familiar with
that organization. Dr. Lettsom, somewhat
younger, a protege of Fothergill, was a most
picturesque figure. He was bom in Tortola in the
West Indies, was taken to London when very
young, was educated there, and was apprenticed
to an apothecary. But the financial affairs of his
family were in a bad way, so he returned to Tor-

January, 1941

21

MEDICAL SOCIETIES AND MEDICAL PROGRESS— COLE

tola where he arrived with £50 in his pocket. His
first act was to liberate his slaves. Then he prac-
ticed medicine on the island and in six months
had made £2000. He gave half to his mother,
returned to Europe, took his M.D. degree in
Leyden, and started in practice in London, where,
probably aided by Lothergill, he soon had an
enormous practice and is said to have made as
much as £12,000 in a single year. There are a
half dozen versions of the famous play on his
name, of which this is one,

I, John Lettsom,

Blisters, bleeds and sweats ’em

And if then they choose to die,

I, John, lets ’em.

Dr. Lettsom was not a graduate of an English
university and therefore could not become a fel-
low of the College, so he started a society of his
own, the London Medical Society. This society
is still in existence. It has occupied an important
place in the history of English medicine and, es-
pecially in its earlier years, gave to its members
a position of greater importance in the eyes of
the public, increased the self-respect of the less
well educated and less prosperous members, and
aided in their development and education.

Philadelphia M'cdical Society. — In the Ameri-
can colonies, during the very early period, clergy-
men, carrying out what Cotton Mather called
the “Angelical Conjunction,” had acted as doc-
tors as well as priests. But in the 18th century,
before the Revolution, this practice had been
largely given up and the care of the sick was
mainly in the hands of men with almost no
medical training at all. There was plenty of sick-
ness, doctoring was profitable and many un-
trained men hung out their shingles. After the
middle of the century there was a sprinkling of
men, mostly from Boston and Philadelphia, who
went abroad to study medicine, chiefly in Lon-
don and Edinburgh. They became the leading
men here and were instrumental in starting the
societies in this country. Among them were two
especially, who played important parts in the
development of medicine in this country, John
Morgan and William Shippen. Both were Phila-
delphians and both studied under Eothergill and
received their medical degrees from Edinburgh.
Shippen returned in 1762, started in practice and

at the same time gave lectures in anatomy, the
first systematic anatomical lectures ever given in
this country. Morgan came back three years later,
the best educated, and reputedly the most talented
doctor in America. Soon after his return, Mor-
gan was made Professor of the Theory and
Practice of Medicine in the College of Phila-
delphia, and this was the beginning of the first
medical school in this country, later to become
the Medical Department of the University of
Pennsylvania. On May 3, 1765, he delivered his
“memorable and prophetic” address on medical
education, which proposed standards that were
only realized 100 years later. Shippen was of a
jealous, envious disposition; he felt that Morgan
was stealing his thunder, and as a result these
men became bitter rivals and enemies, with un-
fortunate results for the future of medicine in
America.

Although Shippen, after his return from
Europe, had made an effort to start a medical
society, nothing came of it. But no sooner had
Morgan returned than he started the Philadel-
phia Medical Society (1765), the first significant
society to be organized on this side of the water.
Morgan invited all the leading doctors of Phila-
delphia to become members, with the exception
of William Shippen and his father. This certain-
ly did not help to narrow the breach between
the two rival professors. However, the society
did not last long. After three years it was com-
bined with the Society for Promoting Useful
Knowledge, which had been started by Eranklin
in 1743, to form the American Philosophical So-
ciety which is still in existence. Although doctors
were active in the Philosophical Society, Phila-
delphia remained without any real medical society
from 1768 until 1787. During this period the
revolutionary war was fought, and Shippen and
Morgan continued their rivalry, now more seri-
ous. At the outbreak of the war Morgan had
been made director general of the hospitals, but
through Shippen’s connivance, Morgan was dis-
missed from the army and Shippen was put in
his place. In retaliation, Morgan had Shippen
court-martialed. At one time Shippen even had
Morgan put in jail for slander. It was a bitter
struggle and left Morgan a broken man. He
retired from active life, although he held his
professorship until his death in 1789.

College of Physicians of Philadelphia. — In
1787, the war being over and quiet being restored,

22

Jour. M.S.M.S.

MEDICAL SOCIETIES AND [MEDICAL PROGRESS— COLE

a new society in Philadelphia was organized, the
College of Physicians of Philadelphia, and in the
choice of the name, the members were undoubt-
edly influenced by the name of the oldest medical
society in England. Its real parent, however,
was the Edinburgh Medical Society. “Weir
Mitchell used to say that genealogically our Col-
lege was the child of Edinburgh and the grand-
child of Leyden.” Though Morgan took no
active part in the organization of the new so-
ciety, it is certain that it was different than it
would have been without the influence which he
still exerted. However, another man had now
taken his place at the head of the medical
affairs in Philadelphia. Benjamin Rush, ten
years younger than Morgan, had also studied in
Edinburgh and London, and on Morgan’s death
became his successor. Rush was cast in a dif-
ferent mold from Morgan, much more practical
and ready to make compromises, much more
a man of affairs, politically minded, he lacked
Morgan’s idealism. He was neither a great stu-
dent nor a scientist. John Redman was made
president of the College, but Rush gave the
introductory lecture. In this address Rush laid
stress on the relation of the society to the gov-
ernment. His attitude toward the scientific pro-
gram was neither very imaginative nor stimulat-
ing. Among other things, he said “a fellowship
in our College will become in time not only the
sign of ability but an introduction to business.”
This address is of much interest as it was the
first promulgation in this country of the purposes
of a medical society. It was, on the whole, an
able address, but it lacked the insight, idealism
and inspiration of John Morgan’s speech on edu-
cation made 25 years before.

The College was not established to grant de-
grees ; that was taken care of by the university.
Nor was it even intended to be a teaching institu-
tion. At first it took quite an active part in public
health and other matters. During the yellow
fever epidemics, the question whether the dis-
ease was of local origin or whether it was in-
fectious and imported from without, was very
violently discussed at frequent meetings. The
college held at all times that the disease was
imported and spread by contagion. Benjamin
Rush took the opposite view, holding that the
disease was he result of filth in the streets of
the city. He felt so strongly about this, and
about the attitude of the society, that, in 1797,

he resigned from the College. In 1802, Lettsom
sent to the College a supply of vaccine virus, and
he was made an honorary member. On the
other hand, Jenner, who was also proposed, failed
of election. So do the wisest sometimes fail to
recognize the source of important new knowledge.

With the passing of time and the development
of other organizations, the need for the College
to trke an active part in public affairs became
less pressing, and the society “tended more and
more to function as a purely scientific body,
dedicated chiefly to the exchange and publication
of scientific reports based on individual research
and practice.” The meetings are held monthly
and a number of lectureships have been endowed.
The library has always been one of the most
important features of the College and it is now
one of the important medical libraries of the
world. It has almost 150,000 volumes, including
over 400 incunabulse. Largely because of the
library, the physicians of Philadelphia have al-
ways been interested in medical literature and
culture.

In later years, even among the fellows, the
ciiticism has been expressed, just as it has been
in the case of its namesake in London, that it
is not as active as it should be, that it should
take more part in public affairs. It may be
pointed out, however, that the accomplishments
of this society, though in part intangible, have
been and still are very great. The medical profes-
sion in Philadelphia has always been distinguished
for its character, its learning and its devotion to
the traditions of medicine. In no city in the
country has the profession been held in higher
esteem by the people. For all this the College
may take a good share of the credit. Societies,
like men, cannot be measured entirely by their
activities. What men are may be as important
as what they accomplish.

This society is important, not only because
of its age and history, but because it is a type
of society that has been frequently imitated in
this country. These societies have usually
been called academies, or, in some cases, in-
stitutes, not because they are teaching organi-
zations but because they are intended to be
chiefly scientific associations, with the mem-
bership limited to the more worthy and best
educated members of the profession. Many of
these academies have also developed libraries.

J.^NUARY, 1941

23

MEDICAL SOCIETIES AND MEDICAL PROGRESS— COLE

The Academy of Medicine in New York,
founded in 1847, now has a library of almost
250,000 volumes, and is exceeded in size, in
this country, only by the Library of the Surgeon
General in Washington. Some of the academies
have maintained the high scholarly and scientific
ideals which at first distinguished them. Others
have become largely interested in medico-political
matters and, with propriety, can hardly be dis-
tinguished as Academies, as that term is generally
understood.

New Jersey State Medical Society. — Societies
with a less restricted membership, and concern-
ing themselves to a considerable extent with
medico-political and medico-social affairs, began
to be organized very early in this country. In
1766, there was organized the New Jersey State
Medical Society with 17 members. This society
was formed for the purpose of controlling medi-
cal practice in the state and for regulating fees.

It is still in existence and is claimed to be
the oldest medical society in the United States.
However, it was only legally incorporated in
1790, and, therefore, the glory attached to be-
ing the oldest medical society still existing in
the United States is claimed by the Massachu-
setts Medical Society, which was incorporated
in 1781. Wisely, the Massachusetts Society
refrained from dealing with the matter of fees,
and, by its charter, control of medical practice
in the state was placed in its hands in per-
petuity. It was from the first an organization
for regulating practice, not a scientific society.

That it was very conservative is shown from
the record of its relations with Benjamin Water-
house, the Professor of Medicine at Harvard,
who introduced vaccination into this country.
Apparently the society felt it should go very
slowly in this matter. It was not until 1808, ten
years after the publication of Jenner’s Inquiry,
and nine years after Waterhouse had success-
fully vaccinated seven of his own children, that
the society put itself on record as convinced of
the value of vaccination. Of that contribution to
medicine which is probably the greatest ever
made in this country, certainly in Massachusetts,
the introduction of ether anesthesia, the society
apparently remained blissfully unconscious. In

the history of the Massachusetts Medical So-
ciety of 500 pages, ether anesthesia is not even
mentioned. In spite of all this, the society became,
in later years, a dignified, useful corporation, con-
trolling the licensing of physicians in Massachu-
setts until the passage of the medical practice
act in 1914, and it has succeeded in maintaining
the profession in the state at a high level.

Michigan and Other State Societies.— M.3.\v\y
with the purpose of controlling the licensing of
practitioners, a large number of state and county
medical societies were formed during the first
half of the nineteenth century. It is undoubtedly
a source of great pride to you that in 1820, when
there were societies in only eight of the states,
all of them on the Atlantic seaboard, a medical
society was organized by the doctors living in
the far-off Territory of Michigan. Only three
years before. Dr. John L. Whiting had arrived
in Detroit, on horseback, to practice in what was
then practically a wilderness, with only a few
scattered settlements inhabited by fur traders.
He had come from New York State, where a
state medical society had been organized ten
years before. He brought together seven doctors,
three from Detroit, and one each from Pontiac,
St. Claire, Mount Clemens and Monroe, and
organized a medical society — seven members,
four of them officers. As you know, your so-
ciety has not had an uninterrupted existence, but,
except for the name, the present society is the
same one organized by Dr. Whiting one hundred
and twenty years ago.

American Medical Association

By 1844 societies had been established in 15
states, only three of them, including Michigan,
west of the Alleghanies. To the annual meeting
of the New York State Medical Society, in that
year, there came a young delegate from Broome
County, named Dr. Nathan Smith Davis, only 27
years of age. He had been born on a small farm
in Northern New York, his mother died when
he was seven years old, and he had had a difficult
childhood and youth ; his father had been able
to send him but for a single term to the neigh-
boring Cazinova Seminary. When 17 years of
age, he commenced to study medicine in the
office of a county doctor, and at 20 he received
a diploma from the College of Physicians and

24

Tour. M.S.M.S.

MEDICAL SOCIETIES AND MEDICAL PROGRESS— COLE

Surgeons of Western New York. He practiced
for a few months in a small village, was mar-
ried, and then moved to Binghamton, Boone
County. It is obvious that his formal education
was as meagre as can be imagined. But young
Davis had health and he was determined to have
an education. While practicing, he studied in
every spare moment, and before ver}^ long, be-
sides rapidly becoming a leading doctor in his
town, he was lecturing to classes in the Bingham-
ton Academy on physiology, botany, chemistry
and other subjects. He was elected secretary of
his county society in 1841, librarian in 1843, and
the following year he was made a delegate to the
state society. If any one could know how ineffi-
cient the medical education of that day was,
young Dr. Davis should. And he felt very
strongly about it. So, at this, his first meeting
of the State society, he introduced some resolu-
tions, declaring “ a four months college term too
short for an adequate course of lectures on all
the branches of medical science, and the stand-
ard of education, both preliminary and medical,
required by the schools previous to the granting
of their diplomas, altogether too low.” It seems
almost unbelievable, in the light of the extent
and complexity of present-day medical educa-
tion, that less than 100 years ago, in even the
best medical schools of this country, a four
months’ lecture course was considered sufficient
to impart to the prospective doctor all that was
known of medical science and practice. Dr. Davis’
resolutions gave rise to some discussion, but they
were merely referred to a committee, of which
Dr. Davis was made chairman. During the year,
he persuaded most of the county societies of the
state to sanction the principles they contained,
and the next year the committee reported. Dr.
Davis, of course, again strongly recommended
the resolutions, but another member brought in
an unfavorable report. He said that the require-
ments of the colleges in New York State were
as high as those of the other states, and that
if they were made more strict in New York,
the students would leave the colleges in New
York and go elsewhere. Dr. Davis, therefore,
offered a resolution to the effect that a National
Convention of delegates from all medical schools
and colleges in the countr}'- be called, to meet in
New York City in 1846, for the purpose of adopt-
ing some concerted action on the subject of the
standards of medical education. Some of the

opposition declared the project “utopian, im-
practical and undesirable.” The resolutions, how-
ever, were adopted by the society, and Dr. Davis
spent a busy year getting in touch with so-
cieties, colleges, editors and prominent physicians
throughout the country. And he didn’t have a
corps of assistants and stenographers either!

As a result of his efforts, on May 5, 1846,
eighty delegates from colleges and state societies
throughout the nation met in New York and
decided to form a National Medical Association.
One year later, a second meeting was held at
Philadelphia, with 250 delegates present, and at
this meeting resolutions were passed recommend-
ing an increase in the medical course from four
to six months and that students should be re-
quired to attend two full courses of lectures. It
was further decided to make the organization a
permanent one and to name it The American
Medical Association.

It is well for us not tO' forget that this society
was founded as the result of the desire to im-
prove medical education on the part of a young
man, Nathan Smith Davis, who himself had been
deprived of the benefits of a formal education,
but who became one of the best educated men
of the profession.

The great improvement in medical education
which has since occurred has, of course, not been
due solely to the American Medical Association,
but this society has never wavered in its out-
spoken advocacy of the highest standards, and
certainly, without the support of organized medi-
cine, reforms would have been very difficult. You
all know of the other great accomplishments of
the American Medical Association.

British Medical Association

The British Medical Association was started
in a somewhat different manner and with a dif-
ferent purpose. In 1832, through the efforts of
Dr. Charles Hastings, a general practitioner of
Worcester, there was organized the Provincial
Medical and Surgical Association. Unlike Dr.
Davis, Dr. Hastings was not greatly interested
in improving medical education, there was less
need for this in England, but he was very de-
sirous of improving the quality of the general
practitioners. While, at first, membership was
restricted to the doctors of the provinces, in 1856
London was included, and the name of the asso-
ciation was changed to the British Medical Asso-
ciation. The British and American Associations,

January, 1941

25

MEDICAL SOCIETIES AND MEDICAL PROGRESS— COLE

therefore, were founded for different reasons
but their methods have been very similar.

Special Societies

With the gradual improvement in medical edu-
cation during the latter part of the century, there
occurred a great movement toward specialization
in medicine and the development of national
societies devoted to the various specialties. The
first of these societies, the American Otological
Society, was founded in 1866, and this was fol-
lowed by the Neurological Society in 1875, and
later by other societies representing all the va-
rious specialties, These societies are of great
importance, not only because they bring together
men of common interests, but because they pro-
mote the discussion of clinical and, to some
extent, scientific problems without the confusion
resulting from the introduction of economic, so-
cial and political questions into their delibera-
tions. While not all these societies are animated
by exactly the same spirit and high ideals, their
general purpose may be well illustrated by read-
ing to you a paragraph from the presidential
address of the first president of the Association
of American Physicians, Dr. Francis Delafield,
in 1885. This address is probably the shortest
one ever given in like circumstances and, in my
humble opinion, is one of the best. It consisted of
but three paragraphs, the second of which is the
following ;

“We all of us know why we are assembled
here today. It is because we want an association
in which there will be no medical politics and
no medical ethics ; an association in which no
one will care who are the officers and who are
not; in which we will not ask from what part
of the country a man comes, but whether he has
done good work and will do more ; whether he
has something to say worth hearing, and can
say it. We want an association composed of
members, each one of whom is able to contribute
something real to the common stock of knowl-
edge, and where he who reads such a contribu-
tion feels sure of a discriminating audience.”

It is of interest that in 1907, under the influ-
ence of Dr. Osier, a society having similar pur-
poses was organized in Great Britain, the Asso-
ciation of British Physicians. Thus did England,
from which we obtained ideas regarding medical
societies in the eighteenth century, come to us
for models in the twentieth.

Societies for Experimental Studies

Such rapid changes have occurred in medicine,
especially in America, during the past forty
years, that no discussion of medical societies
would be complete without touching on some of
the changes that have occurred in them. During
the last few years of the last century, the study
of the fundamental nature of disease by experi-
mental methods was increasing rapidly, but it
was largely carried on by those wFo were pro-
fessionally chiefly interested in the underlying
sciences, though a few doctors, working in the
university clinics and hospitals, and a very" few
men working independently, were also busy. One
of these men was Dr. Samuel Meltzer of New
York. He had studied in Europe under the
German clinicians and scientists of that period.
He came to this country in 1883 to undertake
practice and to engage in the study of disease.
But there were very few laboratories in wFich
such studies could be undertaken. He built up
a practice in New York, but the inquiring spirit
did not die. After visiting his patients, he would
drive to the physiological laboratory of the Col-
lege of Physicians and Surgeons, tie his horse to
a lamp post, and perform some physiological
experiment. Many experiments were also car-
ried out in his own little house, often late at
night. Dr. Meltzer was unique in his insistence
on the importance of societies for stimulating
research. With a few like minded men, in 1903,
he organized the Society of Experimental Biolog}"
and Medicine which soon became familiarly
dubbed the Meltzer Verein. It has now grown to
have a membership of over 1,500, with 13 sec-
tions scattered over this country, Canada and
China. The contributions of the members now
number over eleven thousand and fill forty-three
volumes.

But Dr. Meltzer was not satisfied with found-
ing only one society. In 1908, recognizing that
there was not room in the Association of Amer-
ican Physicians for the rapidly increasing num-
ber of scientific physicians, he w"as instrumental
in organizing the American Society for Clinical
Investigation, which has been of very great value
in giving recognition and stimulus to the younger
members working in experimental medicine and
in giving them a forum for the presentation and
discussion of their work.

A recently organized medical society is the
American College of Physicians, founded in 1915.

26

Jour. M.S.M.S.

MEDICAL SOCIETIES AND MEDICAL PROGRESS— COLE

Besides offering- a meeting place for considering
and discussing clinical and scientific topics, it is
attempting, through organized effort, to improve
postgraduate teaching and to establish minimum
standards for those specializing in internal medi-
cine. It, therefore, is more directly concerned
with problems of professional organization and
regulation and with controversial matters than
the other organizations I have just mentioned.

Its board of registration, in collaboration
with boards representing the other specialties,
and with members representing the American
Medical Association, pass on the qualifica-
tions of those desiring to be regarded as spe-
cialists. The number of candidates so far as-
cepted is over 11,000. Truly the profession is
becoming specialized!

Time will not permit me to discuss the large
number of smaller societies that have been or-
ganized during the present century, some of
them with original and unique functions.

Lessons Learned

The study of history is very pleasant and in-
teresting, but it can only affect our lives if from
it we can draw conclusions and learn lessons.
From the resume of the history of medical so-
cieties, which I have presented so inadequately,
it is evident that the various societies were
founded for various reasons. This is not so
obvious, however, if one only reads their con-
stitutions. It has been said that “a. man always
has two reasons for doing anything — a good rea-
son and the real reason.” Constitutions usually
state the good reasons. There is a striking simi-
larity in the constitutions of all medical societies,
just as there is in the constitutions of all coun-
tries established during the past 150 years, or,
at least, until recently, when constitutions came
to be considered superfluous. All these con-
stitutions start with the statement that the pur-
pose of the government is to promote liberty,
welfare and happiness of the people, although too
often these beneficent purposes are soon for-
gotten. So the constitutions of the medical so-
cieties usually state that they are founded to
promote the science of medicine, improve the
education of their members and promote public

health, or words to that effect. To find what
they have really stood for, it is necessary to be
informed of their later activities.

From the very beginning, aside from their
interest in scientific matters, medical societies
were active in solving the economic and political
problems confronting the profession. They were
interested in the regulation of fees, the qualifica-
tions for practice, improvements in education,
the behavior of physicians toward one another,
medical ethics, the suppression of cults profess-
ing unusual doctrines, the relation between physi-
cians and hospitals, and more recently, resistance
to special groups who would introduce what they
mistakenly believe to be reforms in medical prac-
tice, but which, if carried out, would be harmful
to the public welfare.

During the past fifty years, two important
trends in the activities of medical societies have
taken place. First, there has occurred a great
movement toward organization of the profession
in order to solve medico-political and medico-
social problems. Second, in the scientific field
there has occurred a striking tendency toward
specialization in the societies. While there are
great possibilities for good in both of these trends,
there are also dangers which should not be dis-
regarded.

Organization emphasizes the importance of the
mass and tends to diminish the significance of
the individual, who thus loses in self-respect and
public esteem and may become less interested in
his own development. It tends to magnify the
importance of the organizers and to lay stress
on qualities which are entirely foreign to scientific
or professional abilities. If not resisted, there is
always danger that group interests may become
paramount to public interests. Organization by
special groups has become widely prevalent. The
Workers Alliance, the Tariff Lobby, the Trades
Unions, the Townsendites, the Big Navy Boys,
the Farmer Group, the American Legion, the
Youth Congress, and hundreds of other groups,
all organized to promote their own interests, give
rise to the fear that the public interest may be
forgotten. It is important to keep in mind the
fate of the guilds and companies, which had lost
their usefulness by the second half of the 18th
century. As one historian has said^ “the medieval
form of association was incompatible with the
new ideas of individual liberty and free com-
petition. . . . Intent only on promoting their own

January, 1941

27

MEDICAL SOCIETIES AND MEDICAL PROGRESS— COLE

interests and disregarding the welfare of the
community, the old companies had become an
unmitigated evil.” Fortunately, in the medical
organizations, there has as yet been no indication
of putting selfish interests above the common
welfare.

Advantages and Dangers of Medical Societies

The second tendency in our societies, that of
specialization, is also not without dangers. I am
referring here not so much to the societies whose
interests are in the various special fields of
medicine, but rather to the tendency to make
a sharp division between those men who are
investigating disease and widening the boundaries
of knowledge and the great mass of physicians
who are applying this new knowledge, with a
corresponding separation of their societies, It
was unfortunate enough when the chemists and
physiologists and anatomists became far removed
from the medical profession. That special so-
cieties should be organized by those who are
engaged in particular kinds of research is inevi-
table, but these societies should not be the only
ones interested in adding to knowledge. It has
recently been suggested that men desiring to
undertake research in medicine should have a
special kind of training, starting very early in
life. Otherwise, they had better forget about it.
We may next hear of a D.M.R. degree — doctor
of medical research, and the next step would be
an organization formed to prevent all those not
having this degree from making discoveries.

Since the boundaries of knowledge have be-
come so widened, it is manifestly impossible for
those without very specialized knowledge and
training fully to comprehend certain fields, much
less contribute tO' them. But all additions to
knowledge do not come from added refinements.
Most great advances are made through original
conceptions and novel combinations of known
facts. The day is not passed when discoveries
can be made by amateurs. In any case, the im-
portance to the individual lies not so much in
succeeding as in trying. “What I aspired to be.
And was not, comforts me.” The scientist is one
with an inquiring mind. Every physician cannot
be a great discoverer, but every physician must
be a student, and be ever anxious to learn new
truths for himself, and not depend solely on
authority, if our medical profession is to con-
tinue to be a learned, scientific one and not

merely a technical craft. I have recently been
interested in reading extracts from the diary and
note books of Edward Jenner, all his life an
active practitioner, with no laboratory and few
resources. One day he was dissecting a swallow
killed at mid-day. Shortly afterwards he was
taking the temperature of a hedge-hog; this as
a result of a letter to John Hunter asking for
information, which brought the well-known reply,
“But why think ? Why not try ?” A few days
later he was dissecting a horse that died at the
Kennels, “suffering from the Staggers.” Read-
ing this material, one is convinced that the dis-
covery of vaccination for smallpox was not solely
an accident.

Medical education now supplies the physician
with an enormous amount of factual knowledge.
No other business or profession requires so long
a period of preparation. But mere acquaintance
with a wide range of facts does not make a man
a student, a scholar or a scientist. The wisest,
the most learned, or even the most efficient men
are not the stars of the “Information Please”
program. Civilization itself does not depend on
the extent of the known. We must still bow to
the Greeks, though they possessed almost no ac-
curate knowledge of natural phenomena.

Education only makes scholars, students, scien-
tists and cultivated men when it so influences
them that they remain forever students, scholars
and investigators, not mere craftsmen. To accom-
plish this seems to me to be the function of the
local societies and academies. The great national
societies, holding meetings but once a year, cannot
greatly stimulate the originality of the individual
or give him opportunity for self expression.

The local society is the meeting place of men
with inquiring minds, a place where members
can present the results of their observations and
studies. What the subjects of the communica-
tions are is not so important. Ever)' piece of
work faithfully, honestly and seriously perform-
ed is worthy. They need not all be experimental
investigations, though the more of these the
better. They may even be historical studies.
Indeed, the report of a group of cases, or even
of a very special case, may be of significance.

With the present view that physicians must
know about everything relating to medicine, he
is afraid to stop long enough to learn all he can
about anything. The opportunities for rapid
diffusion of new knowledge offered by the mul-

28

louR. M.S.M.S.

MEDICAL SOCIETIES AND MEDICAL PROGRESS— COLE

titude of medical journals, to say nothing of the
newspapers, enable physicians to obtain a speak-
ing knowledge of new discoveries before the ink
is hardly dry on the reports. I sometimes first
learn from men in remote districts of new dis-
coveries made by my associates at the Rocke-
feller Institute. Sometimes scientists are accused
of “knowing more and more about less and less.”
The physician must guard against knowing less
and less about more and more.

Special stress should be laid on the importance
of libraries for the local societies. Next best to
having one’s own libraiy- is to have easy access
to a librar}’ owned by the society to which he
belongs. The collection of books is of great
educational value and every local society can
have at least a small librar}-. Interest should not
be confined to contemporaiy" publications. Of
much importance is the collection of older books
having historical significance.

In my opinion, the programs of the local and
county society meetings can be of most value
if the members themselves present the papers.
Communications by specialists from distant cities,
giving the results of their own experiments and
observations, may be of value, but it is the train-
ing of the members themselves that is of greatest
importance. Post-graduate courses, given by
professional teachers, are in certain places veiy*
useful, but none of these methods give the same
stimulus to study and work as do reports by the
members themselves. Of course these should be
more than hastily prepared notes or papers writ-
ten without study and effort. Real lasting
knowledge only comes through living “laborious
days.”

A presentation by a member may not be of
great interest to all his colleagues. It may even
require some self-sacrifice on the part of his
hearers. But your turn will come and you also
will want an audience. The speaker has learned
much even though you have learned little. I well
remember dining one evening at- the house of
Dr. Osier. Several young physicians were
present, one of them socially-minded, and with
a talent for singing pleasant ditties. After din-
ner he was seated at the piano, singing to amuse
us and the ladies, when Dr. Osier stopped at the
door. “Aren’t you going over to the hospital
to the medical society meeting?” he asked. The
singer stopped long enough to say “Oh, I don’t
get much out of these medical society meetings.”

“Do you think I do?” Dr. Osier replied, and
closed the door, not too gently. Needless to say,
we all rather shamefacedly followed him.

The success of a local society depends, of
course, on the quality of its members. As you
all know, certain classes in college and medical
school stand out above the others. This has not
been due entirely to chance, but it has occurred
because in these classes there were a few men of
exceptional ability who set a rapid pace. The
great societies have become great largely because
of the high ideals and abilities of certain mem-
bers. I have alreadv mentioned Thomas Linacre,
William Harvey, Lorenz Bausch, John Lettsom,
John Morgan, Charles Hastings, Nathan S. Da-
vis, William Osier, Samuel Meltzer.

It is only natural that physicians should be
interested in the great economic and social prob-
lems that concern the profession as a whole, but
there is always the danger that he allow these
interests to usurp a dominating place in his so-
ciety activities. In societies there are not in-
frequently a few men who are politically minded,
who often know more about parlimentaiy^ rules
of order than they do about the science of medi-
cine, who are possessed of the furor disputandi.
If these men come to control the society, it is
likely to become a debating club given over to
passing resolutions. There is no habit so futile
and time consuming. I know of no men more
addicted to this vice than doctors, unless it be
college faculties.

. Medical societies have been and can be of
very great value. By expressing the combined
opinion of the members, they can make an ef-
fective appeal to the public, can bring about
medical reforms and can institute new projects
of importance for the welfare of mankind. More
important than their political effectiveness, how-
ever, is the influence which they exert on the
members themselves and the stimulus they can
give to greater endeavors. Probably most im-
portant of all is the pleasure and joy they can
afford the members, not only the pleasure of
attempting higher accomplishments, but also the
joy of harmonious and sympathetic association
with fellow members in a learned and scientific
profession.

If I seem to have offered a counsel of per-
fection, let us remember the old saying that “in
shooting an arrow one must aim high in order
to reach the target.”

January, 1941

29

SINUSITIS— STEFFENSEN

Sinusitis

Orbital Complications

By W. H. StefTensen, M.D., F.A.C.S.

Grand Rapids, Michigan

W. H. Steffensen, M.D.

M.D., University of Michigan, 1931. Mem-
ber, American Academy of Ophthalmology and
Otolaryngology. Fellow, American College of
Surgeons. Diplomate, American Board of
Plastic Surgery. Attending Staff _ Blodgett
Memorial Hospital. Member, Michigan State
Medical Society.

■ This paper was prepared with the hope of

outlining a more uniform method of approach
to the treatment of orbital cellulitis and orbital
abscess resulting from sinus infections. The lit-
erature on the subject is meager. I am impressed
by the variations in operative treatment in those
cases requiring surgery.

Orbital complications of sinusitis are danger-
ous because they can result in serious damage to
the eye, or proceed to still more serious sequelae
— namely: osteomyelitis of the cranial vault,

generalized sepsis, meningitis, dural sinus throm-
bosis, or brain abscess.

The mode of transmission of an inflammatory
process from the sinuses to the orbit may be by
(1) thrombophlebitis, (2) direct extension
through dehiscences, or (3) erosion of the com-
mon party wall between the affected sinus and
the orbit. Thrombophlebitis plays also the impor-
tant role in causing this localized osteomyelitis.
It was formerly believed that the common route
of extension of infection to this area was by way
of the lymphatics, but anatomical facts pointed
out by Turner and Reynolds, and corroborated by
Rouviere and his colleagues, suggest otherwise.

Approximately one-half of the entire area of
the bony wall of the orbit is also the bony wall of
the nasal accessory sinuses. The lateral boundary
of the ethmoid capsule is the thinnest of the sinus
walls. The ophthalmic artery, superior and in-
ferior ophthalmic veins with their tributaries
(principally the ethmoid vessels) are contained
in the orbital cavity. The posterior ethmoidal
artery furnishes almost the entire blood supply
of the ethmoid labyrinth. It is apparent why its
accompanying vein is so frequently involved in
a process of thrombophlebitis extending infection
to the orbit.

Hitz, in 1933, stated that ethmoiditis and max-

illary sinusitis were the most common sources of
orbital infections, but gave no percentage figures.
The majority of those reporting cases have dem-
onstrated that the ethmoid labyrinth is the most
common source of orbital infections, with the
frontal sinus standing second in importance. The
antrum is very important in young individuals,
while the sphenoid sinus seems to serve as the
focus only rarely. Porter in a comprehensive
review of sixty cases stated that 75 per cent were
secondary to sinusitis and the ethmoid cells were
involved in every case. Eighty-two per cent of
his cases were in children. The mortality rate
was 5 per cent. Such figures are representative
of all statistical reviews on the subject.

Diagnosis

Porter classified the various stages of orbital
infection. The first stage is simple edema of the
eyelids. The reaction in the second stage has pro-
gressed to exophthalmos and in the third stage
there is chemosis of the conjunctiva with com-
plete fixation of the globe.

Examination of the nose usually reveals the
typical picture of an acute sinusitis. An absence
of nasal signs of infection in the presence of an
acute sinusitis is rare. One or all of the sinuses
may be infected. Good x-ray films are invaluable
in diagnosis and choice of the method of treat-
ment. Preference should be given to some modi-
fication of the Rhese position to visualize the
ethmoid cells through the orbital soft parts and
avoid overlying bone shadows. Positions for vis-
ualization of the other sinuses are well stand-
ardized.

Treatment

Conservative. — Treatment of the sinusitis in
the first stage of an orbital inflammation will
consist of the use of shrinking solutions (pref-
erably ephedrine), warm saline irrigations, steam
inhalations and internal medications. Suction
should be looked upon with disfavor because of
the hyperemia which follows its use.

Conservative measures usually cease to be of
value when the orbital infection has passed the
stage of simple edema of the eyelids. Most of
the successful cases of conservative treatment
have occurred in young individuals because chil-
dren with sinusitis are most susceptible to edema
of the orbital contents.

30

Jour. M.S.M.S.

SINUSITIS— STEFFENSEN

Sinus Drainage. — Sinus drainage is indicated
if the orbital involvement is increasing, if the
temperature remains elevated and there is defi-
nite sinus suppuration. This is particularly true
if there has been a previous attack of sinusitis or
an acute exacerbation of a chronic sinusitis with
severe pain. The most conservative surgical pro-
cedure which will provide free drainage with a
minimum of trauma is the one of choice.

The presence of an orbital cellulitis does not
necessarily indicate sinus drainage. The sinusitis
itself or later intracranial complications may in-
dicate it. Therefore, in the presence of progres-
sive symptoms from the stage of simple edema
of the eyelids, it is safer to operate once too often
than to wait too long. Lederer has stated ‘'Those
who have voiced an ultra-conservative attitude
have probably experienced in their own hands or
in those of their colleagues, unfortunate sequelae.”

The customary procedure in the case of orbital
inflammation requiring sinus surgery is to infract
or remove a portion of the middle turbinate, or to
perform a partial ethmoidectomy intranasally.

Orbital Abscess —

The treatment of an orbital abscess com-
plicating sinusitis is always urgent, more ur-
gent than that of an acute mastoiditis. The
indications of an orbital abscess are an in-
creasing and brawny edema of the eyelids and
conjunctiva, a fixed and displaced eyeball and
excessive pain. Confusion of this condition
with the early stage of cavernous sinus throm-
bosis is clarified by careful observation of de-
tails.

There is no single sign which permits a dis-
tinction between a simple collateral edema and an
orbital abscess. Localized tenderness of the or-
bital wall, localized palpable infiltrations, pro-
nounced chemosis, fixation of the eye and dis-
placement of the globe downward and outward
have all been regarded as signs of abscess in
contradistinction to simple edema. None of these
signs are decisive singly.

Pus from the frontal sinus usually erodes the
thin bony floor just medial to the supra-orbital
notch, forming an orbital abscess between the
bone and the orbital periosteum. Similarly, pus
from the ethmoid cells tracks through the thin os
planum or the extension occurs by way of the

orbital vessels. The abscess in either case is
like a collar-stud (Davis). A collection of pus
lies between the bone and the orbital periosteum,
a second collection of pus is situated in the af-
fected sinus and the two are connected by a pyo-
genic tract. It is essential to drain both collec-
tions of pus, and particularly that in the nasal
accessory sinus. It is also important to respect
and avoid injury to the orbital periosteum which
forms an effective barrier between the abscess
and the delicate orbital contents.

Operative Procedure

Lederer states; “We frequently have found it
necessary to advise surgical procedures in ac-
cordance with the ability of the surgeon.” It is
not logical to advise the less experienced opera-
tor to work in the ethmoid capsule intranasally
where the vision is poor and is made worse by
profuse bleeding; where distortion of anatomical
landmarks has occurred due to edema ; and
where one is limited in his inspection of the in-
fected areas to be drained.

The best judgment of a skilled operator on-
ly can determine the presence of suppuration
deep in the orbit before pointing has occurred.
This can best be investigated by aspiration
or exploratory incision under direct vision.
Intranasal frontal drainage is always danger-
ous and the Killian type of procedure carries
a high mortality rate statistically.

Sinus Drainage. — The most feasible approach
to a drainage of the upper group of sinuses
where there is an indication for more distant in-
vestigation or drainage through the periorbita as
well as drainage of the infected sinuses, attacks
both problems at the same time. It consists in
the use of the fronto-ethmo-sphenoid technic as
perfected by Lynch, Sewell and Ferris Smith.
This permits direct inspection of the principal
ethmoid vessels as they enter the ethmoid laby-
rinth. One frequently finds abscess formation
about these vessels. It permits inspection of the
orbit to its apex. The periorbita can be aspirated
or incised diagnostically.

The ethmoid labyrinth is entered through the
lachrymal fossa region and these cells are drained
under direct vision. The frontal sinus can be
drained at this point by removal of a portion of
its floor. A Penrose drain is inserted into the

January, 1941

31

INDUSTRIAL HYGIENE— NEAL AND BLOOMFIELD

depth of the cavity and the wound left open for
free drainage. The sinuses can be thoroughly
operated at a later date, if indicated, and the
wound closed with a minimum of visible scar.

The operative procedure is accomplished in
a practically bloodless field under direct vi-
sion. It has the distinct advantage of thor-
oughly draining the infected areas and is done
with technical safety and a minimum of
trauma in an area already overwhelmed by
infection, where accidents resulting from work-
ing blindly through the nose or inadequate
drainage would be hazardous.

Bibliography

1. Davis, E. D. D., Mygind, S. H., Howells, G. H., and

Capps, F. C. W. : Discussion on orbital cellulitis due to

sinus infections and its treatment. Proc. Roy. Soc. Med.,
30:1397-1407, (Sept.) 1937.

2. Hitz, J. B. : The management of orbital infection secondary

to sinus infection. Wisconsin Med. Jour., 32:318-321,
(May) 1933.

3. Lederer, F. L. : Fulminant sinus disease. A study of

pathogenesis. Surg. Gyn. and Obst., 60:645-656, (March)
1935.

4. Porter, Chas. T. : Etiology and treatment of orbital in-

fections. Ann. Otol., Rhin. and Laryng., 41:1136-1141,
(Dec.) 1932.

5. Rouviere by M. J. Tobias — Anatomy of the Lymphatic
System. Edwards Brothers, Inc., 1938.

6. Smith, Ferris: Roentgen study of the spheno-ethmoid

sinuses. Arch. Otol., 24:762-764, (Dec.) 1936.

7. Smith, Ferris: Management of chronic sinus disease.

Arch. Otol., 19:157-171, (Feb.) 1934.

8. Turner, A. L., and Reynolds, F. E. : A study of paths

of infection to the brain, meninges and venous blood
sinuses from neighboring peripheral foci of inflammation.
Jour. Laryng. and Otol., 41:73-86, 1926; 41:442-453, 1926;
41:717-731, 1926.

MISSISSIPPI VALLEY MEDICAL SOCIETY
1941 ESSAY CONTEST

The Mississippi Valley Medical Society offers an-
nually a cash prize of $100.00, a gold medal, and a cer-
tificate of award for the best unpublished essay on any
subject of general medical interest (including medical
economics) and practical value to the general practition-
er of medicine. Certificates of merit may also be
granted to the physicians whose essays are rated second
and third best. Contestants must be members of the
American Medical Association who are residents of the
United States. The winner will be invited to present
his contribution before the next annual meeting of the
Mississippi Valley Medical Society at Cedar Rapids,
Iowa, October 1, 2, 3, 1941, the Society reserving the
exclusive right to first publish the essay in its official
publication — the Mississippi Valley Medical Journal
(incorporating the Radiologic Reziew) . All contribu-
tions shall not exceed 5000 words, shall be typewritten
in English in manuscript form, submitted in five copies
and must be received not later than May 1, 1941. The
winning essay of the 1940 contest appears in the Jan-
uary, 1941, issue of the Mississippi Valley Medical
Journal (Quincy, 111.). Further details may be secured
from Harold Swanberg, M.D., Secretary, Mississippi
Valley Medical Society, 209-224 W. C. U. Building,
Quincy, Illinois.

Industrial Hygiene

Responsibility of the Medical
Profession*

By Paul A. Neal, Surgeon
and

J. J. Bloomfield, Sanitary Engineer
U. S. Public Health Service
Washington, D. C.

Paul A. Neal, M.D., Washington, D. C.

M.D., Vanderbilt University, 1927;
Commissioned as Assistant Surgeon,
Regular Corps, U. S. Public Health
Service, 1928; 1929-34, on duty in Eu-
rope, attached to Consular Office on
Foreign Quarantine detail; 1934 to
present tune. Division of Industrial Hy-
giene, National Institute of Health; at
present Action Chief, Division of In-
dustrial Hygiene. Member A.M.A.,
American Public Health Association,
American Association for the Advance-
ment of Science, American Association
of Industrial Physicians and Surgeons,
and Association of Military Surgeons.

■ The legal responsibility for protecting the
health of our gainfully employed is a func-
tion of official public health agencies. Na-
turally, the cooperation of the medical profes-
sion is essential in accomplishing this end. Fur-
thermore, for the attainment of practical results,
we need the combined efforts of personnel
from several of the scientific professions, es-
pecially those of the physician, the engineer, and
the chemist. The present contribution is an
example of such teamwork, having been pre-
pared by a physician and an engineer. This
was done purposely in order that both view-
points would be treated.

Interrelations

The problems of industrial hygiene must be
attacked on two fronts. First, we must attack
those problems concerned with the hygiene of
the individual, and, second, those dealing with
the environment in which the individual works
and lives. The first function comes within the
scope of the medical sciences and the second
deals with engineering practices.

It is within the province of the medical pro-
fession to diagnose diseases and primarily to
recognize the existence of such diseases as may
be due to the working environment; while,
based on the findings of the physician, the

^Presented before the Michigan State Medical Society meeting.
Friday, September 27, 1940, Detroit, Michigan.

Jour. M.S.M.S.

32

INDUSTRIAL HYGIENE— NEAL AND BLOOMFIELD

engineer is in a position to learn what un-
healthful conditions should be investigated and
where control measures are to be initiated.

It is essential, therefore, that the various
professions clearly understand the functions
of each and approach the solution of the prob-
lems in industrial hygiene as a joint effort, and
cooperate with each other to the fullest extent.

It is well known that environmental condi-
tions in certain work-places can contribute to
diseases among workers which are unique to
a particular occupation, and which do not exist
in the non-industrial population. However, as
will be shown later, occupational accidents and
specific occupational diseases, although consti-
tuting an important problem in industrial hy-
giene, do not account for the major part of the
time lost due to disability. It is apparent, there-
fore, that in addition to the problem of con-
trolling accidents and occupational diseases,
we are confronted also with the important task
of the control of all diseases, which are just
as common, and more important economically,
among industrial workers as among those of
the general population. Hence, the fact is evi-
dent for considering industrial hygiene as a
function of the general field of public health.

It is for this reason that the medical profes-
sion plays such an important role, since it is
one of the chief concerns of that profession to
assist in the promotion of better health in the
community.

Industrial Program

If every plant had an industrial health main-
tenance program, and if every State health de-
partment had a comprehensive industrial hy-
giene service, then our problem today would
not be so difficult. However, recent studies^
made by the United States Public Health Serv-
ice of health service facilities in a large number
of industrial establishments, as well as those
conducted by the National Industrial Conference
Board,® indicate that such services are still far
from meeting our needs. For example, in the
Public Health Service analysis of approximately
17,000 establishments employing 1,500,000
workers in fifteen representative States, it was
found that only 15 per cent of the employees
were provided with the services of a full-time
physician. These data are sufficiently repre-

sentative to conclude that 85 per cent of our
workers are without such full-time services.
This is especially true in those plants employ-
ing less than 500 people. We may assume,
therefore, that the bulk of our gainfully em-
ployed, when in need of medical services, re-
ceive them from the private practitioner, be
it on a part-time basis at the plant, from “on
call” physicians, or from the family physician.
This is especially true with reference to the
so-called non-occupational disabilities. The
National Industrial Conference Board study
showed that, in one-third of the plants sur-
veyed by them, no efforts were made to su-
pervise non-occupational disabilities, in order
to assure the worker of medical attention. This
study also showed that in only slightly more
than one-half the plants was an effort made
to promote employee health through educa-
tional means, and that only casual supervision
was practiced with regard to working condi-
tions. It is a well-known fact that the physi-
cian who spends but one or two hours a day
in a plant, as well as the one who merely goes
to the plant when called, has not the time to
devote to a program of disease prevention.
This state of affairs, therefore, calls for serious
consideration on the part of the medical pro-
fession regarding its responsibility in the im-
portant field of industrial hygiene. This re-
sponsibility assumes even greater importance
today with the increase in industrial activities
resulting from our National Defense Program.

In order to cope effectively with this prob-
lem, it would seem essential that we first gain
some knowledge of its nature and scope. In
other words, before we may discuss what steps
may be taken by the medical profession and
others, and what opportunities industrial medi-
cine offers, we must first examine the extent
of the problem.

Nature and Extent of the Problem

It should not be necessary today to justify
the necessity for industrial hygiene by citing
the abundant statistics available on the sub-
ject. However, in order to visualize the prob-
lems confronting us, it may be well to reiterate
certain facts. Today we still witness annually
approximately 17,000 occupational deaths from
accidents, 75,000 permanent disabilities and
1,400,000 temporary disabilities. We still have
many problems arising from diseases peculiar

January, 1941

33

INDUSTRIAL HYGIENE— NEAL AND BLOOMFIELD

to certain, occupations, such as silicosis, lead
poisoning, and the dermatoses. It is also
known from many studies that industrial work-
ers have higher rates of physical defects than
non-industrial workers, and that excessive
mortality is especially notable in unskilled
workers, among whom the death rate from all
causes is 100 per cent or more in excess of the
death rate among agricultural workers. It has
also been well established that the average
worker in this country loses 10 days a year on
account of sickness and that the amount of
time lost from general illnesses is in the
neighborhood of 15 times as great as the total
amount lost from both accidents and occupa-
tional diseases.

We may expect all of these problems to be
magnified with the present expansion of indus-
trial activities.

Present Practices in Industrial Hygiene

Industry is becoming more and more aware
of its responsibilities concerning the protec-
tion and improvement of the health of its em-
ployees. This is especially true of the larger
plants, which are in a better position economi-
cally to deal with this problem than the small
plant, which finds it very expensive to pro-
vide more than a limited industrial health ser-
vice to its workers. Some data have already
been cited concerning the health service facili-
ties now existing in industry. The National In-
dustrial Conference Board study clearly shows
that such services are on the increase, and of
late have been extended to include not only
the prompt treatment of injuries and diseases
arising from occupational exposure, but have
also included such other services as dental,
ocular, x-ray, and educational programs for
health promotion. Many plants have also in-
cluded programs for systematic study of the
working environment in an attempt to control
deleterious exposures, while others have es-
tablished programs designed to diminish the
time lost from general illnesses.

Many non-official agencies have of late be-
come deeply interested in, and concerned with,
the problem of employee health. Some of these
agencies, such as the Air Hygiene Foundation,
are primarily supported by industry itself.

The Federal Government, of course, has

been active in this field for many years. The
United States Public Health Service has had
an organized Division of Industrial Hygiene
since 1914. Its functions may be considered as
partly administrative, concerned with coordi-
nating all activities, both at the Federal and
State level, the promotion of industrial hygiene
services in State and local health departments,
and investigations carried on in the laboratorv
and in the field. All of these activities are con-
ducted in cooperation with State agencies, with
industry, with the medical profession, and
with the other professions and organizations.

The growth in the number of State health
departments providing services in industrial
hygiene has been almost phenomenal during
the past four years, under the stimulation of
the funds provided by the Social Security Act.
Today there are thirty-one states with indus-
trial hygiene services, employing nearly 150
professional personnel and spending approxi-
mately three quarters of a million dollars for
this activity. It is realized, of course, that the
present State services are limited, due to in-
sufficient funds and trained personnel.

If the Public Health Service and the State
health departments are to be of any great as-
sistance to industry and the medical and en-
gineering professions in the conserv^ation of
manpower, we shall have to provide more
funds and more trained personnel. One of the
important needs today is training centers for
personnel, so that the demands in industrial
hygiene for physicians, engineers, and chemists
may be met.

Role of the Medical Profession

It has been stated by authorities in the field
of industrial hygiene that the major types of
activity are medical and surgical care to effect
prompt restoration of health and earning ca-
pacity following disability, the prevention of
disability in industry by the proper control of
the working environment, and, finally, the
promotion of health among workers. For those
physicians holding positions in industry, and
especially those completely responsible for fur-
nishing an industrial health maintenance pro-
gram, the Council on Industrial Health of the
American Medical Association^ has suggested
a definite program.

34

Jour. M.S.M.S.

INDUSTRIAL HYGIENE— NEAL AND BLOOMFIELD

This program consists of such functions as
periodic inspection and appraisal of plant sani-
tation and occupational exposures, followed by
the adoption and maintenance of adequate con-
trol measures. The provision of first-aid and
emergency services and the prompt and early
treatment for all illnesses resulting from occu-
pational exposure are very important functions
of the medical department. Impartial health
appraisals of all workers, the provision of re-
habilitation services for the correction of de-
fects are additional functions of a medical de-
partment. And, finally, by means of recording
and reducing absenteeism due to all types of
disability and the conduct of a health promo-
tion program, it should be possible to make
real progress in reducing lost time among
workers, thereby benefiting not only the worker
as regards his physical health, but also yield-
ing tangible benefits of a monetary nature to
both the employer and the employee.

The Council on Industrial Health of the
American Medical Association has been very
active in stimulating the contributions which
the physician individiudly , and through rnedi-
cal organizations, can make to the health of the
industrial worker. The Council has also stimu-
lated the formation of committees on industrial
hygiene in State and county medical organiza-
tions, and has clearly outlined a program
which could be adopted by the State and local
societies. The program of activities which has
been formulated for these committees contains
the following objectives:

1. Train physicians to recognize and report occupa-
tional disease.

2. Train industry and labor to the value of indus-
trial health conservation.

3. Elevate medical relations and standards under
workmen’s compensation.

4. Scrutinize all social legislation affecting industrial
health.

5. Clarify relationships between industrial and pri-
vate practitioners.

6. Improve relations between physicians and insur-
ance.

7. Establish working relationships with all State
agencies interested in industrial health.

We should like to expand further on several
of the objectives listed.

First, it is highly essential that physicians
inform themselves further concerning occupa-
tional diseases, so that they will recognize
such diseases more readily in the course of

their practice. It would be advantageous for
a private practitioner to make this effort, in
view of the fact that he may be called upon to
diagnose and treat such ailments in the course
of his everyday practice.

In this connection, it is pertinent to stress
one other important item, namely, the neces-
sity for obtaining an accurate and detailed oc-
cupational history. We all know to what great
lengths physicians go to obtain an accurate
and detailed personal and past medical history
on a patient, yet, often neglect to obtain in-
formation concerning the man’s exposure to
toxic materials in industry. In view of the fact
that a man’s occupation may have a real bear-
ing on his health, it is highly essential that a
history of his occupation be obtained in de-
tail and interpreted properly. Such an inquiry
may often necessitate investigating the pa-
tient’s working environment or at least ob-
taining information on this point from the
proper plant officials, as well as from the pa-
tient himself. For example, a recent investiga-
tion by the Public Health Service has indicated
that manganese poisoning may often be mis-
taken for multiple sclerosis or Parkinson’s
disease.

With further reference to the subject of oc-
cupational diseases, it should by now be ob-
vious that unless the physician, be he in in-
dustry or in private practice, promptly reports
to the proper authorities the occurrence of oc-
cupational diseases among workers, it will be
next to impossible for the official agency re-
sponsible for the control of such diseases to*
carry out its functions. Physicians should
adopt the same attitude toward the reporting
of occupational diseases which now exists with
regard to the reporting of communicable dis-
eases. The recurrence of such diseases may be
obviated by a prompt investigation on the part
of a State industrial hygiene service of those
conditions in the plant which may be the caus-
ative agent. Once this has been established,,
prompt measures may be taken T'or the control
of the environmental conditions responsible
for the diseases.

In addition to the responsibilities which the
medical profession has with regard to occupa-
tional diseases and other functions cited here-
in, still another obligation should be given

January, 1941

35

CARCINOMA OF THE LARGE BOWELL— HARTZELL

consideration. This deals with advising the in-
dividual patient regarding his health. The
physician is the only one to offer such advice
and it is likely that he will have more success
in doing so than any other single individual.
The patient’s cooperation should be enlisted
not only in the prevention and control of dis-
eases arising out of the occupation but also in
the promotion of general health and mental
well-being.

The medical profession can make still an-
other important contribution in the field of in-
dustrial medicine by stimulating the preem-
ployment and periodic physical examination of
workers in industry, and by calling attention
to the necessity for correcting those physical
defects revealed by a health examination.

Cooperation with Agencies

We have repeatedly stressed the need for
cooperating with the local health agencies,
which are responsible for protecting the health
of workers. The private practitioner, either as
an individual or through his State and local
medical organization, should utilize to the full-
est extent the services which may be rendered
by the official industrial hygiene division, and
through it the facilities available in the entire
health department. Some of the services which
may be rendered by these official agencies are :

1. Consultation with plant management regarding
needed corrections of environmental conditions.

2. Advice to the management and medical super-
visor as to the relative toxicity of materials or pro-
cesses, and advice concerning new materials prior to
their introduction into the industry.

3. Assistance in developing, maintaining and analyz-
ing absenteeism records.

4. Consultant service to medical supervisors, private
physicians, compensation authorities and other State
agencies regarding illness affecting workers.

5. Provision of necessary laboratory service of both
a clinical and physical nature.

6. Integration of the activities of other public health
bureaus in their programs for workers ; for example,
the control of cancer, syphilis and tuberculosis.

We have attempted to define some of the
problems of industrial hygiene, the methods
employed in their solution, and the contribu-
tion which the medical profession can make to-
ward the maintenance of employee health. Dr.
Selby has once said that every physician in in-
dustry should consider himself as the health
officer of that industry. We should like to
recommend that more emphasis be given to
this viewpoint, not only by the full-time in-

dustrial practitioner, but also by the private
practitioner in his contact with the industrial
patient. It is only by such a viewpoint and ap-
proach that we may hope to make the progress
necessary for the conservation of the health
and efficiency of our millions of workers.

References

1. Bloomfield, J. J., et al. : A preliminary survey of the indus-
trial hygiene problem in the United States. Public Health
Bulletin No. 259, 1940.

2. Council on Industrial Health, American Medical Association:
Industrial Health. Reprinted from Jour. A.M.A., 114:573-586.
(February 17) 1940.

3. National Industrial Conference Board, Inc. Medical and
Health Programs in Industry, No. 17. Studies in Personnel
Policy. 1939.

Carcinoma of the Large BoweF

The Problem of Early
Diagnosis

By John B. Hartzcll, M.D., F.A.C.S.

Detroit, Michigan

John B. Hartzell, M.D.

M.D., College of Medicine, University of
Cincinnati, 1925. Fellow of American College
of Surgeons. Chief of the Department of
Surgery, Charles Godwin Jennings Hospital.

Associate Surgeon, Receiving Hospital, Detroit.

Assistant Professor of Clinical Surgery, Wayne
University. Member, Michigan State Medical
Society.

" Carcinoma of the colon is usually slow of

growth and metastasizes late, and therefore
early treatment ought to yield favorable results.
However, despite the relatively lower grade of
malignancy usually found in these growths, the
mortality is high, suggesting that:

1. Either such lesions give no early intima-
tion of their presence,

2. The patient has a tendency to regard such
symptoms as unimportant,

3. The physicians underestimates the symp-
toms,

4. Diagnostic methods are not adequate, or,

5. The patient ignores the advice of the
physician.

At a recent meeting of the American Society
for the Control of Cancer, a letter was read from
an electrical engineer,^ aged twenty-nine, who
had an inoperable carcinoma of the pelvic colon.
This young man, a well educated layman, had
presented himself to his physician because of a
bowel complaint. His physician treated him for

*From the Department of Surgery of ^yayne University and
the Surgical Service of the Charles Godwin Jennings and Re-
ceiving Hospitals, Detroit.

36

Jour. M.S.M.S.

CARCINOMA OF THE LARGE BOWELL— HARTZELL

four months for colitis during which time he
steadily lost ground. He then went to a clinic
in a small hospital and there was given the
same diagnosis, later going to another physi-
cian in a nearly city where he received more
treatment for colitis. Finally, ten months from
the time he first presented himself to a physician,
a barium enema was administered, and a fluoro-
scopic examination revealed a large carcinoma.
The lesion was inoperable and a colostomy was
all that could be done. This individual had be-
come reconciled to his fate, and with but a few
short months to live, he writes :

“My message to you of the medical fraternitj' is,
do not hesitate to make the worst diagnosis first. Say
the bad news; then, if desirable, attempt to disprove
it, but under no circumstances are you justified in try-
ing to get the layman to report his symptoms early
only to be stalled along in the diagnosis until an in-
operable lesion has developed. All of the efforts to
educate the layman are commendable, but much remains
to be done to educate the physician to recognize the
symptoms and not to hesitate in diagnosing them.”

That this letter indicates that the patient is not
always at fault, in that he seeks aid late in the
disease, is evident, and suggests that the reasons
for discovery of carcinoma of the colon late in
the disease may be those expressed in points 3
and 4 above. We have analyzed the histories of
cases of carcinoma of the large bowel which
came to us late in the disease, in an attempt to
determine, if possible, why therapy was delayed
so long. Obviously, such an analysis of cases is
difficult so far as determining exactly where the
trouble lies and is important only in that it might
point out pitfalls in diagnosis or provide a better
understanding of the causes of delay. It is also
to be recognized that after all the data is available
and the diagnosis is assured, it is much easier
to recognize points of significance in the histoiy^
and physical examination than it is before the
facts are known and clarified. The following
cases are illustrative of some of the causes for
delay in adequate therapy for carcinoma of the
large bowel.

Typical Cases

Lesions which gave no early intimation of
their presence or early symptoms were ignored
by the patient:

Case 1. — ^A sixty-year-old obese man was well until
five days before admission, when he began to lose
appetite and notice marked fatigue. Two days prior

to admission he took a laxative with good results, but
felt worse. The next day he began to have lower
abdominal pain and became distended, also had a
chill and began to vomit. Examination — He appeared
acutely ill, temperature 101 degrees, pulse 120. His
abdomen was obese with moderate general distension.
There was generalized muscle spasm, and the lower
abdomen was tender on palpation. Leukocyte count
was 34,200 per c.c., 93 per cent polymorphonuclear
neutrophils. The patient was treated expectantly for
one week, (duodenal suction, intravenous fluids and
transfusions). As soon as his general condition per-
mitted, a proctoscopic examination was made which
was negative, but the barium enema revealed a stenos-
ing lesion of the sigmoid. A cecostomy was performed.
The patient went home one week later much improved.
One month after the cecostomy, the lower portion
of the descending colon and sigmoid was resected for
a carcinoma. There were no palpable metastases in
the liver, but there were numerous glands in the ad-
jacent mesentery. There was evidence of an old
perforation. It is but six months since the operation
and the patient has remained well.

Case 2. — A sixty-year-old white man had suffered
from hemorrhoids. Two 3^ears ago he saw a physician
who recommended operation. One year ago the hem-
orrhoids commenced to protrude at inter\^als. At the
same time he was passing small stools eight to ten
times daily. He finally sought medical advice for his
hemorrhoids at which time a stenosing cancer of the
rectosigmoid was found. An abdomino-perineal re-
section was performed. The patient has remained well
for six months. Despite the long period of time elaps-
ing before operation was performed there were no
gross metastases to the liver.

Lesions in which the physician underesti-
mated the importance of the symptoms or
signs :

Case 3. — ^A man, aged seventy-four years, consulted
his physician in a neighbouring town because of vague
abdominal distress — belching and bloating. He also
complained of tiring more easily than usual. He was
given powders and advised to go on a vacation, but
there was no improvement. Three months later a
large tumor was palpated in the right side. Exploratory
laparotomy revealed a carcinoma involving the greater
portion of the ascending colon and hepatic flexure.
This was fixed posteriorly. An ileocolostomy was per-
formed, and the distal stiunp of the terminal ileum
closed. The patient remained in good health for one
5’ear after the operation. Recently, the tumor has in-
creased in size, and the patient shows signs of in-
creasing weakness.

Case 4. — A sixty-year-old man was treated by the
family doctor for one and one-half years for attacks
of cramplike abdominal pain and constipation. An
x-ray was finally advised which showed marked gaseous

January, 1941

37

CARCINOMA OF THE LARGE BOWELL— HARTZELL

distension of the colon and terminal ileum. The patient
was admitted to the surgical service almost completely
obstructed, and a cecostomy was performed. There
was no gross involvement of the liver or lymph glands.
Two weeks later 9 cm. of the descending colon was

Case 6. — A male, aged sixty years, was admitted with
a history of attacks of cramplike abdominal pain, in-
creasing constipation of two months duration, and loss
of twenty pounds in weight. The sigmoidoscopic ex-
amination was negative. A barium enema was reported

Fig. 1. Roentgenogram of a barium
enema, showing the left half of the colon
well distended with barium. This was re-
ported as normal by the roentgenologist.

Fig. 2. A re-examination in the oblique
view shows a stenosed filling defect at the
juncture of the descending colon and sig-
moid which was obscured in the first ex-
amination.

resected for an annular tumor which proved to be
malignant. An end-to-end anastomosis esablished
continuity. It is now one and one-half years since
the operation and the patient has remained well.

Lesion in which inadequate diagnostic meth-
ods were used even after malignancy was sus-
pected :

Case 5. — A fifty-one-year-old man consulted a physi-
cian because of a six months history of attacks of
nausea, vomiting, and increasing constipation with a
seventy pound weight loss. He was hospitalized eigh-
teen days. A barium enema showed partial obstruc-
tion at the splenic flexure from what was considered to
be a benign tumor. Surgical consultation was not rec-
ommended, so that exploratory laparotomy was not
performed. The patient was allowed to go home with
the recommendation that he return for frequent ob-
servation. Three months later he was no better and
when admitted to the surgical service had an almost
complete obstruction which was diagnosed as carcin-
oma of the splenic flexure. Exploration revealed a large
tumor mass of the splenic flexure densely adherent to
the greater curvature of the stomach. This was mobil-
ized, the stomach wall repaired and an obstructive re-
section performed. Continuity was later established
by crushing the spur and closing the colostomy. It is
now over two years since the operation and the patient
has remained well, despite the fact that he was oper-
ated upon late after local extension had occurred.

as negative (Fig. 1). The history was suggestive of an
obstructive lesion in the colon and a reexamination with
an oblique view was insisted upon. This revealed a
stenosed filling defect in the descending colon which was
obscured in the first examination (Fig. 2). An ob-
structive resection was performed, continuity being
established later by crushing the spur, with closure of
the colostomy. The patient remained well for only
one year, dying recently of generalized carcinomatosis.

Cancer of the large bowel accounts for about
one-tenth of all deaths from malignant disease.
Unfortunately, it is quite impossible to delineate
a symptom complex by which early carcinoma of
the large bowel may be diagnosed, and it must be
remembered, as has been pointed out by Fansler
and Anderson,^ that the symptoms to emphasize
are not those which convince one that carcinoma
is surely present, but rather those which indicate
that carcinoma may possibly be present. Gen-
erally speaking, the easier it is to make the diag-
nosis the less the possibility of halting the fatal
progress of the disease. In its incipiency, cancer
of the bowel may be absolutely silent. Gradually,
however, certain mild changes in bowel habit, or
a vague abdominal distress may induce the pa-
tient to consult his physician. If this individual

38

Jou«. M.S.M.S.

CARCINOMA OF THE LARGE BO WELL— HART ZELL

is of a nervous type, and for years has exag-
gerated various complaints to his physician, he
will more than likely receive reassurance and a
placebo, rather than a painstaking examination.
The frequency of this bad error is stressed by
Steindl,^® who reports a series of inoperable
carcinomas of the large bowel in which 22 per
cent had become inoperable because of errors
in diagnosis. This is well illustrated by Case 3,
and in retrospect, what would seem to be an in-
excusable delay is represented in Case 5, since all
data necessary for an accurate diagnosis were
available.

Most Common Early Signs of Carcinoma
of the Large Bowel

1. Some change in bowel habit. This may
be so slight that it is not considered of any
importance by the patient who may believe it
to be a transient upset. There may be a brief
return to normal bowel habit, with a later re-
currence of symptoms of irregularity of stool.
There may be signs of increasing intestinal ir-
ritability with periods of diarrhea. There may
also be present alternating periods of consti-
pation.

2. There may be persistent localized pain
or tenderness.

3. There may be marked weakness with as-
sociated anemia and without visible loss of
blood.

4. A tumor may be palpated. This does not
necessarily mean an advanced lesion, as even
a small carcinoma with ulceration may develop
about it a large inflammatory mass.

5. Blood in the stool, or streaked upon the
stool, may signify a low ulcerating growth.

6. Intestinal obstruction, of varying degrees
of severity, usually indicates an annular lesion
which has been present at least one year. Ca-
chexia, marked loss of weight, with general
debilitation, usually indicates advanced malig-
nant disease with metastases.

7. Occasionally, the insidious early symp-
toms may be overlooked by the patient, and
the first sign of the presence of a large bowel
malignancy may be the result of a perforation
or an obstruction. Case 1 is illustrative of an
onset of symptoms beginning with what Ran-
kin^^ has described as “explosive suddenness.”

Why these Symptoms?

To understand the chain of symptoms pro-
duced by carcinoma of the large bowel, we must
consider the right and left halves of the colon
as separate organs. Rankin^^ has repeatedly
stressed the importance of this fact. The cecum,
ascending colon, and the right half of the trans-
verse colon, together with the small intestine up
to the papilla of Vater, are developed from the
mid gut. The function of this portion of the
intestine is chiefly that of digestion and absorp-
tion, and the bowel content is fluid or semi-solid.
Carcinomas situated in the right half of the
colon are usually large flat ulcerating lesions.
They interfere with the absorptive mechansim
of the mucous membrane, and owing to the great-
er diameter of the ascending colon, and the fact
that the content is usually of fluid consistency,
obstruction does not occur as commonly.

The early symptoms may be considered as
“dyspepsia,” with or without localized tender-
ness.

This often suggests chronic appendicitis,
chronic cholecystitis, or duodenal ulcer. In a
series of 100 cases of carcinomas of this segment
of the colon reported by Priestly and Bargen,^”
20 per cent had been previously subjected to
celiotomy after the onset of symptoms ascrib-
able to cancer. Fifteen had had appendectomies,
one an operation on the biliary tract, and there
were four exploratory laparotomies.

In other individuals suffering from malig-
nant lesions in the right colon, the first sign
may be weakness. The patient presents him-
self to the physician because of unexplained
fatigue and inability to perform his usual daily
work. Such an individual is usually dehydrated
and examination will usually reveal a marked
anemia, without visible loss of blood.

Occasionally, however, early carcinomas of this
segment of the large bowel are devoid of any
symptom whatsoever, and fall into the so-called
silent group. Such a lesion is discovered by
accident or in the course of a routine physical
examination. A tumor may be palpated, or as
in most lesions of the right colon, the barium
enema will reveal a filling defect which is later
proved to be malignant. This is moderately well
illustrated by Case 1.

January, 1941

39

CARCINOMA OF THE LARGE BOWELL— HARTZELL

The left half of the transverse colon, together
with the descending colon, sigmoid and rectum,
are developed from the hind gut, and their func-
tion is chiefly that of storage. The wall is thicker
and stronger than on the right side, and by the
time the intestinal content reaches this segment
of the large bowel the water has largely been
absorbed, and the stool becomes formed. Ma-
lignancies here tend to encircle the bowel, re-
sulting commonly in varying degrees of obstruc-
tion. Frequently constipation, sometimes al-
ternating with diarrhea, is a predominant com-
plaint, as illustrated by Case 2.

In 125 cases studied by Rosser,^® he found
that two-thirds of those in which the growth
was situated in the descending colon showed
constipation and colic, while one-quarter had
diarrhea.

As the proximity of the growth approaches the
rectum, the incidence of frank blood increases.
Rankin^^ states that bleeding occurs in 90 per
cent of carcinomas of the rectum at some stage
of the disease. For those in which the growth
is situated beyond the reach of the sigmoido-
scope, the barium enema in the hands of the
expert roentgenologist will reveal filling defects
which are usually accurately interpreted. At
the hepatic and splenic flexures, in the sigmoid
or low down in the descending colon, it is of
the greatest importance to visualize the barium
enema in the lateral and oblique, as well as the
antero-posterior view. Here normal superim-
posed bowel in the antero-posterior view may
cover up a filling defect which would be over-
looked unless seen in the oblique view. This
point has been emphasized by Gordon- Watson,®
and is well illustrated by Case 6. If a barium
enema is negative and malignancy is suspected,
the examination should be repeated in two to
four weeks. Often a second barium enema will
reveal a filling defect not present or not noticed
at the time of the first examination. Lehman,®
Feldman® et al. have stressed this point.

Rectal Examination

It seems obvious that digital examination of
the rectum should be a routine part in any
complete physical examination, and while the
importance of this procedure cannot be too
strongly stressed, we must emphasize that the
examination should go further. Too many

individuals are subjected to hemorrhoidectomy
when further examination would reveal the
presence of a carcinoma beyond the reach of
the examining finger.

In 28 per cent of a large series observed by
Rankin and Graham^® the patient had been sub-
jected to hemorrhoidectomy after the onset of
symptoms of carcinoma. Jones® states that 75
per cent of rectal carcinomas are first diagnosed
as hemorrhoids. This error is by no means
always the fault of the physician. Occasionally
a patient, knowing he has hemorrhoids will as-
cribe the symptoms of malignancy to his known
condition and delay further examination. Case
2 is illustrative of such an oversight on the part
of the patient.

For those growths within the reach of the
sigmoidoscope, direct visualization and biopsy
offers the ideal method of arriving at a diag-
nosis. If microscopic examination of the tissue
removed is positive for carcinoma, the diagnosis
is conclusive. A negative report, however, may
mean that the biopsy was not taken deeply
enough, and a second specimen may show the
presence of malignancy. There is frequently a
piling up of non-malignant mucosa membrane
along the border of a carcinoma. In Figure 3, a
photomicrograph of a malignant lesion of the rec-
tosigmoid is presented through the courtesy of
Dr. Osborne Brines,^ who has frequently empha-
sized this point. Through the sigmoidoscope, this
bunched-up area appears to be a good one from
which to secure a biopsy, (Area B, Figure 3),
but this may show no cancer. Here it will be
noted that in the vicinity of A the mucous mem-
brane is normal, while in the vicinity of B there
is hypertrophy with piling up of the mucous
membrane. This area is frequently even more
elevated and conspicuous by the presence of
swelling from edema and secondary infection
about the carcinima. A positive biopsy would
have to be secured rather deeply from the vi-
cinity of C. Dukes^ stresses the importance of
repeating a biopsy if the first is negative.

Likewise, the possibility of multiple lesions
must be kept in mind when making a sigmoido-
scopic study. Recently, the writer, in perform-
ing a sigmoidoscope examination, encountered
a large polypoid tumor about 3 inches above the
anal orifice. Biopsy and microscopic examina-
tion revealed this to be a benign adenoma. This

40

Tour. M.S.M.S.

CARCINOMA OF THE LARGE BOWELL— HARTZELL

diagnosis did not fit into the general picture, and
on repeating the sigmoidoscopic examination we
succeeded in passing the scope beyond this tumor,
and two inches further encountered a typical

ferential diagnosis, since the important thing is
to suspect the presence of malignancy^® Once
suspected, modern diagnostic methods must be
employed with patience and perseverance until

Fig. 3. Photomicrograph through the tissue bor-
dering the rectosigmoid carcinoma removed from the
patient in Case 2. It will be noted that in the vi-
cinity of A the mucous membrane is normal, while
in the vicinity of B there is a marked hypertrophy
with piling up of the mucous membrane. A biopsy is
not infrequently secured from this ring of hyper-
trophied mucous membrane about the neoplasm, and
may show no cancer. Carcinomatous tissue will be
seen beneath the mucous membrane in Area C.

excavating ulcer with firm raised borders which
had completely encircled the bowel (Figure 4).
Microscopic examination of a biopsy from the
border of this area showed it to be an advanced
adenocarcinoma. Resection was performed, and
it is now one and one-half years since operation
and the patient has remained well. Rankin, Bar-
gen and Buie,^^ and Hirschman^ have published
illustrations similar to Figure 4.

Differential Diagnosis

There are other conditions which may simulate
large bowel carcinoma. The most important of
these are : tuberculosis ; diverticulitis ; segmental
ulcerative colitis ; syphilis ; chronic appendicitis.
Each of these conditions may cause a chronic
to an acute inflammatory reaction in a segment
of the large bowel, giving rise to a palpable mass,
with varying degrees of tenderness, pain, and ob-
struction. A benign polyp may also be mis-
taken for malignancy. The expert roentgenol-
ogist can go far in differentiating these lesions.
In some cases a positive diagnosis cannot be
made until the tumor is removed. We need not
worry too much, however, regarding the dif-

January, 1941

Fig. 4. An annular carcinoma of the rectosigmoid
with a polyp distal to it. At the time of the first
proctoscopic examination the patient was uncoopera-
tive and the scope could not be passed beyond the
polyp. A biopsy taken from it revealed it to be
a benign adenoma. On re-examination the scope
was passed beyond the polyp and a positive biopsy
secured from the margin of the ulcerated area.

the presence or absence of malignant disease is
definitely determined.

There were 6,000 deaths from cancer last year
in the State of Michigan.^® This is a terrible toll
and approximates the total number of deaths
from tuberculosis, appendicitis, and automobiles
combined.^® It is further estimated that there
are three living cancer cases for each death.^®
Thus, the total of living cancer cases in Michi-
gan today number 18,000 or approximately three
for every physician in the state. One appalling
fact stands out, that over two-thirds of this group
of individuals are doomed to die of their malig-

41

CARCINOMA OF THE LARGE BOWELL— HARTZELL

nancies, without ever entering a hospital, many
of them without a diagnosis having been made
until the time of death, and all of them without
benefit of any curative treatment whatever. Of
the remaining 30 per cent comprising the group
which will find their way into hospitals, half
will have passed into the advanced stage of
malignant disease and be already doomed. Only
15 per cent of the total will be seen sufficiently
early to effect a cure or prolong life.

Here indeed is an unexplored medical frontier.
The development and standardization of vari-
ous surgical procedures which enable the modern
surgeon to effect a cure in a large percentage of
operations for cancer, are of little avail if 85
per cent of these cases are either never seen by
him, or not seen until they have developed wide-
spread malignant disease.

Certain it is that any improvement in this
unhappy picture will come not only through
education of the general public regarding the
danger signs of early malignant disease, but
also by making ourselves cancer-conscious
physicians.

We must be alert to the early symptoms of
malignancy, and so far as the large bowel is
concerned, we must make a painstaking pur-
poseful examination in those individuals with
vague abdominal complaints, especially when ac-
companied by some change in bowel habit. We
must keep in mind that a negative examination
does not rule out malignancy. A negative digital
or proctoscopic examination may mean a growth
higher up, and a negative biopsy may mean
that the section has not been taken from the
proper area. The possibility of a benign polyp
and a malignant lesion present at the same time
must be remembered. A negative barium enema
must be repeated with especial care being taken
to watch the progress of the enema both in the
oblique and the lateral, as well as the antero-
posterior view, especially in those areas where
there is a possibility of a loop of normal bowel
filled with barium being superimposed so as to
obscure the filling defect of a malignant lesion.

Carcinoma of the large bowel, as malignant
disease elsewhere, is curable if found early.
The lesson of early diagnosis is not only an

important one to impress upon the layman, but
upon the physician as well.

The suspicion that malignancy may be present
should afford adequate stimulus for careful
study, and this study ought to be painstakingly
performed so that the malignant lesions may be
discovered early enough to permit complete erad-
ication.

Bibliography

1. Brines, O.: Personal communication.

2. Dukes, C. : Early diagnosis of carcinoma of the rectum

and colon. Proc. Royal Society of Med., 21:1549-1551,
(July) 1928.

3. Editorial: Moriturus Te Saluto. Jour. Mich. State Medical
Soc., 38:430-431, (May) 1939.

4. Pansier, W. A., and Anderson, J. K. : Cancer of the

colon. Nebraska Med. Jour., 19:361-366, (Oct.) 1934.

5. Feldman, M.: Early diagnosis of cancer of the colon,

roentgenographically considered. Radiology, 22:493-498,
C\pril) 1934.

6. (jordon-Watson, Sir Charles: The diagnosis and treatment

of carcinoma of the colon. British Med. Jour., 1:969-973,
(May) 1932.

7. Hirschman, L. : Synopsis of Ano-Rectal Diseases. St.

Louis: C. V. Mosby, 1937.

8. Jones, D. F. : Diagnosis and principles of treatment of

carcinoma of the colon. Trans. Am. Surg. Assn., 49:308-
318, 1931.

9. Lehman, E. P. : The diagnosis of cancer of the large

bowel. Virginia Med. Monthly, 58:577-583, (Dec.) 1931.

10. Priestly, J. T., and Bargen, J. A.: Early diagnosis of can-

cer of the large intestine. Am. Jour. Surg., 22:515-520,
(Dec.) 1933.

11. Rankin, F. W.: Surgical lesions of the large bowel. Jour.

Mich. State Med. Soc., 31:1-9, (Jan.) 1932.

12. Rankin, F. W. : Modern trends in the treatment of the

rectum and rectosigmoid. Jour. A.M.A., 109 :1719-1723,

(June) 1937.

13. Rankin, F. W., and Graham, A. S. : Carcinoma of the

Colon. American Text Book of Surgery; Ed. by F. Chris-
topher. Philadelphia & London: W. B. Saunders Co.,

1937, p. 1244.

14. Rankin, F. W., Bargen, J. A., and Buie, L. A.: The

Colon, Rectum, and Anus. Philadelphia: W. B. Saunders
Co., 1932.

15. Rector, Frank Leslie: Cancer Survey of Michigan. New

York: Am. Society for Control of Cancer, pages 30-34, 1935.

16. Rosser, C. : Cancer of the anal canal; a survey of 125

cases. South. Med. Jour., 28:527-529, (June) 1935.

17. Rosser, C. : Diagnostic criteria. Jour. A.M.A., 106:109-

112, (Jan.) 1936.

18. Stemdl, H.: Fortschritte in der Diagnostik und Therapie

des Mastdarmkrebses. Wien. med. Wchnschr., 85 :482-484,
(April 27); 518-521, (May 4); 578-582, (May 18) 1935.

19. United States Census Bureau Mortality Rates, 1910-1920,
with Population of the Federal Censuses of 1910 and
1920, and Intercensal Estimates of Population 1923. Wash-
ington: United States Government Printing Office, 1923.

NATIONAL PHYSICIANS' COMMITTEE

Two years of aggressive effort in defining and clari-
fying the issue (political control of medicine), in unify-
ing the profession and informing the public has pro-
duced spectacular results.

In his speech on October 31 at Bethesda, Maryland,
dedicating the National Institute of Health, President
Roosevelt said :

“Neither the American people nor their government intend
to socialize medical practice any more than they plan to
socialize industry. In American life the family doctor, the
general practitioner, performs a service which we rely upon
and trust.

“No one has a greater appreciation than I of the skill and
self-sacrifice O'f the medical profession. And there can be
no substitute for the personal relationship between doctor and
patient which is a characteristic and a source of strength of
medical practice in our land.”

On September 16, in Kansas City, Missouri, Mr. Wen-
dell Willkie said :

“There is no one to whom socialized medicine is more
repugnant than it is to me. I believe in the skill that is
developed by the competitive system.”

42

Jour. M.S.M.S.

SURGICAL DISEASES OF THE COLON— BROOKS AND ASHLEY

Surgical Diseases of the Colon

Diagnosis and Treatment

By Clark D. Brooks, M.D., F.A.C.S. and

L. Byron Ashley, M.D., F.A.C.S.

Detroit, Michigan

Clark D. Brooks, M.D.

M. D., Wayne University College of Medicine,

1905. Attending Sitrgeon at Harper Hospital,

Detroit. Fellow of the American College of
Surgeons; Member of the Detroit Academy of
Surgery; Member of the Detroit Board of
Education; Member of the Michigan State
Medical Society.

L. Byron Ashley, M.D.

M.D., Wayne University Medical Schcol,

1914. ’Associate Surgeon at Harper Hospital,

Detroit; Fellow of the American College of
Surgeons; Member of the Detroit Academy of
Surgery; Member of the Michigan State
Medical Society.

■ Carcinoma of the colon comprised about
ninety per cent of the surgical lesions of that
organ, until about five years ago, as found in
our previous series. Since that time there has
been a gradual increase in the inflammatory
lesions, especially regional colitis and regional
ileitis, the latter with extension into the colon.
We know of no definite reason for the increase
of these particular lesions. There has certainly
been no increase in the amount of roughage
which our diets contain to account for the sharp
numerical rise in the inflammatoiy group. The
present-day overuse of vitamins might be blamed
for this, but in any case, whatever the cause, it
affects the entire population of the countiy% for
reports of an increasing incidence of the condi-
tions reach us from all sides.

Differential Diagnosis

Owing to the irregularity and inconsistency of
symptoms, the diagnosis of carcinoma of the
colon from the clinical histoiy^ and physical ex-
amination is often impossible. Some patients,
when first seen with acute obstruction, give ab-
solutely no symptoms in their past history refer-
able to this disease. Others complain of no
symptoms except weakness or loss of weight ; and
in many cases secondary anemia of unknown
origin is the single clue. Symptoms, such as
blood in stools, constipation, obstipation, diar-
rhea, and bloating, are not constant, as wdll be
observed in the resume of symptoms of this
series.

Rectal, proctoscopic and x-ray examinations
are the most reliable diagnostic procedures and

are indicated early in any case presenting one
or more of the suggestive symptoms.

Regional Colitis. — The most important lesions
to be differentiated from those of carcinoma of
the large bowel are regional colitis, regional
ileitis and inflammation of the diverticulae of the
sigmoid.

Patients with regional colitis present a his-
tory of the passage of mucous or blood or a
combination of both, early in the disease, but
usually by the time the patient is seen there
may be a definite tumor mass present due to
a thickening of the bowel wall from the in-
flammatory condition.

The barium enema x-ray shows the presence
of this tumor mass, along with a definite, uni-
form narrowing of the lumen which may, in
many instances, be difficult to differentiate from
a carcinomatous lesion on account of its likeness
to the napkin-ring type.

Regional Ileitis. — Individuals with regional
ileitis usually have an increase in the number
of daily stools and a change in the character of
the stool.

Cramping pain and bloating appear with
the progressive narrowing of the lumen of the
ileum due to the inflammation present.

The barium enema is first given, to rule out
the possibility of a lesion of the large bowel,
followed by the gastro-intestinal series. The
passage of the barium through the affected area
reveals the definite narrowing diagnostic of this
condition.

In both regional ileitis and colitis, fever and
leukocytosis are higher and more constant than
in malignant growths, while secondaiy anemia is
not so marked.

Diverticulitis. — Patients with diverticulitis
have pain and a passage of mucus and blood per
rectum, and possibly a change in the character
of the stool due to the hyperactivity of the lower
segment of the bowel. The tenderness, while
usually in the lower left quadrant, may be more
toward the midline in many cases.

January, 1941

43

SURGICAL DISEASES OF THE COLON— BROOKS AND ASHLEY

It is fortunate that the pain, tenderness and
rigidity of diverticulitis ordinarily occurs on
the left side of the abdomen. When it does
manifest findings around the midline or even
in the right lower abdomen, difficulty in dif-
ferentiating it from appendicitis is evident, and
the diagnosis often cannot be determined until
operative exploration.

We hesitate to order a barium enema x-ray
examination during the acute phase of diverticuli-
tis, as there is a possibility of rupturing the
inflammatory area.

Many cases of chronic interstitial contracting
diverticulitis simulate malignancy both on x-ray
findings and appearance at operative exposure.
This condition, like regional ileitis and colitis is
increasing in frequency in the last few years.

IntiLSSusception. — Intussusception occurred
three times in our last series of one hundred,
two cases being children and one an adult.

It can usually be diagnosed by the symp-
toms of abdominal pain, passing of mucus or
blood in stools, diarrhea, the presence of ab-
dominal mass, and an x-ray barium enema.

Other more or less important lesions to be
included in the differential diagnosis are internal
and external hernia, benign tumors and strictures,
ulcerative colitis, adhesions and bands encircling
the bowel or otherwise impinging upon the lu-
men, tuberculosis, volvulus, mesenteric throm-
bosis and embolism, Hirschsprung’s disease, im-
perforate anus in infants and polyposis. While
some of these conditions do not present them-
selves as often in the acute or chronic abdomen,
they must always be kept in mind in our dif-
ferential diagnosis.

Pre-operative Preparation

Preliminary Treatment. — The patient with a
lesion of the colon is always either acutely or
chronically obstructed. In the case of the chroni-
cally obstructed, there is sufficient time for prop-
er preparation. Such a patient is usually suffer-
ing from a secondary anemia and it is of greatest
importance that he be given blood preoperatively.
In hospitals maintaining a blood bank this is a
simple procedure, but no matter how much diffi-
culty this entails, it should be given first consid-

eration. Supplementary to the giving of blood the
patient should also be given an adequate prep-
aration with glucose or saline solutions intra-
venously. It has also been our practice to give
colon immunogen, subcutaneously, in graduated
doses. This procedure may be of doubtful value
but we feel that a certain degree of immunization
is thereby obtained. More recently, with the ad-
vent of sulfanilamide therapy, we have been giv-
ing this drug pre-operatively in cases of chronic
obstruction, mainly because of its efficacy in the
treatment of streptococcus and colon infections.
Finally, cevitamic acid, in an adequate dose is
given three times a day, because of the excellent
results obtained in the healing of wounds follow-
ing the use of this vitamin substance. These
drugs may be given parenterally should the pa-
tient be unable to retain medication by mouth.
The diet, pre-operatively, in these patients is lim-
ited to high caloric fluids. In order to thoroughly
rid the bowel of its fecal contents, citrate of mag-
nesia in adequate dosages is used, supplemented
by daily enemata.

Acute Obstruction. — The acutely obstructed
case presents a somewhat different problem of
attack, although we feel that the patient is en-
titled to as much pre-operative support as the time
factor will permit. Every case of this type should
have a flat plate x-ray of the abdomen and, if
possible, a barium enema. In all cases in which
it is necessary to open the bowel a prophylactic
dose of tetanus, B. Welchii and B. Perfringens
is given. Intravenous solutions of glucose and
saline are given slowly in as large amounts as
possible. We prefer the use of a five per cent
glucose solution in physiological saline for this
purpose. Usually the case of acute obstruction
is given blood during the operation, and here
again the use of the blood bank plays an impor-
tant role.

Type of Operation

A two-stage operation is the one of choice for
lesions of the right side of the colon. There is
an increased danger of infection should the one-
stage procedure be carried out, and we feel that
the patient builds up a certain amount of immu-
nity following the first stage, or if this is not
possible, the simple ileostomy is performed. Aft-
er a suitable time the second stage is done, which
consists of a resection of the entire right side of

44

Jour. M.S.M.S.

SURGICAL DISEASES OF THE COLON— BROOKS AND ASHLEY

the colon up to and including the hepatic flexure.
Had the anastomosis between the ileum and
transverse colon not been performed in the first
instance, this is also done as a part of the same
procedure.

We prefer the Paul modification of the Mikulicz’
operation, in lesions of the upper sigmoid, descending
colon and the transverse colon. The lesion is brought
into view and an adequate wedge of mesentery re-
moved. The adjacent walls of the gut are then ap-
proximated, below the lesion, with an intestinal suture,
using an atraumatic needle. It is of greatest importance
that enough of the bowel is freed so that there is no
tension on the loop which is brought up to the surface
of the abdomen, since any drag upon this portion will
give a poor result. The bowel, including the lesion, is
then brought up and the wound closed in layers about
it, the lesion either being left intact, or resected above
the abdominal wall, leaving forceps on the ends of the
colon for two or three days. After the forceps are re-
moved the proximal loop is irrigated with half parts
of saline and olive oil, and when gas and feces are
passing well, a Mikulicz clamp is inserted into each
loop and the partition crushed.

This procedure usually takes four or five days
to accomplish, the fecal current then passing into
the distant loop. Of greatest importance is the
cutting of the spur to a sufficient depth to allow
the free and unobstructed flow of the fecal cur-
rent. If this is properly done, we have found that
the wound closes spontaneously in about half of
the cases and secondary closure is not necessary.
Should secondary closure be necessary, it is not
done before six to eight weeks postoperatively.

We believe that lesions of the lower sig-
moid, the rectum and the anus require a radi-
cal type of procedure, no matter how small the
lesion. It has been definitely shown that these
lesions metastasize early to the surrounding
lymph nodes, so we prefer the abdominal peri-
neal resection with the removal of all the nodes
in the pelvic area. Quite naturally, before this
procedure is carried out a thorough examina-
tion of the liver is made at the time of opera-
tion. Should this organ show evidence of me-
tastasis, a palliative colostomy is in order.

\

Regarding diverticulitis, we never operate un-
less there is perforation with abscess, obstruction
is present, or the condition simulates acute ap-

pendicitis so closely that a diagnosis cannot be
made without operative exploration.

Postoperative Treatment

Utilization of frequent blood chloride and se-
rum protein tests is of great help in maintaining
proper postoperative fluid balance, and indicating
when blood transfusions are necessary. We use
5 per cent glucose in saline or water, by slow in-
travenous drip method. A blood transfusion is
given as routine either during or shortly after
the operation, and repeated as frequently as nec-
essary. Concentrated vitamin C is given routine-
ly, either parentally or by mouth during the full
convalescent stay in the hospital. A Levine tube
with suction is used as a prophylactic measure to
prevent distention. As soon as convalescence is
satisfactory, a high caloric, high protein diet is
given.

The care of the skin around a colostomy open-
ing is important. It should be protected by cello-
phane or oiled silk and a generous layer of zinc
oxide ointment or a paste of bismuth and castor
oil (equal parts). We object to the close fitting
colostomy bags, as they are unsanitary and exert
too much suction on the bowel. Our patients
with permanent colostomies are trained to irri-
gate the bowel with saline solution, and use a
protective rubber or metal cup belt, with vaseline
around the bowel, and cotton or cellucotton dress-
ings. The character of the stool may be regu-
lated by diet and the use of lubricants, or pare-
goric and kaolin mixtures, as the case demands.

Following abdominal perineal resections, the
cavity remaining after removal of the rectum is
treated with irrigations of 2 per cent urea solu-
tion. This fills in quite rapidly, especially since
the use of vitamin C.

Deep x-ray therapy, either pre-operative, be-
tween stages in a two-stage operation, or post-
operatively, is indicated, especially in the ad-
vanced malignant conditions of the colon.

Last 100 Colon Operations

Diagnosis

Carcinoma 78

Regional ileitis and caecitis 6

Obstructing diverticulitis of sigmoid 6

Ruptured diverticulitis of sigmoid 3

Intussusception diverticulitis of sigmoid 3

Tubercular ileitis and caecitis 1

Gangrenous epiploica sigmoid 1

Volvulus of ileum and cecum 1

Fecolith in cecum 1

January, 1941

45

SURGICAL DISEASES OF THE COLON— BROOKS AND ASHLEY

Operation

Modified Mikulicz resection

Colostomy

1 - stage abdominal perineal resection

2- stage abdominal perineal resection

2-stage right colon resection

Cecostomy

End-to-end resection

Elnterostomy

Low resection of rectum

Ileo colostomy

Resection large cancer polyp_ per ^ rectum

Drainage for ruptured diverticulitis

Relief of intussusception

Relief of intussusception and enterostomy.

Removal fecolith in cecum

Removal gangrenous epiploica

CARCINOMA CASES

Sex

Men — 34
Women — 44

Age

Youngest — 28 years
Oldest — 85 years
Average age — 57 years

Pathology

Adenocarcinoma

Polypoid carcinoma

Colloid carcinoma

Cylindrical cell carcinoma

Extension from cancerous stomach
Extension from cancerous ovary. . .
Extension from cancerous uterus.

LOCATION

Sigmoid 39 Transverse

Rectum 14 Splenic . .

Cecum 11 Hepatic ..

Descending 6 Ascending

SURGICAL TYPES

Inoperable cases

7 with liver metastases
2 perforated

Acute obstruction cases

2 perforated

Elective or favorable cases

SYMPTOMS 78 CARCINOMA CASES

Pain

Secondary anemia

Blood in stools

Nausea and vomiting

Bloating :

Constipation

Weakness

Loss of weight

Diarrhea '.

Obstipation

Mass in abdomen

Tenesmus ..i

Small stools

MORTALITY

Inoperable carcinoma and obstructive carcinoma cases
(20 out of 44)

Favorable carcinoma cases

(7 out of 34)

Non-malignant cases (3 out of 22)

1 ruptured diverticulitis with peritonitis

1 obstructing diverticulitis with peritonitis

1 intussusception with mesenteric thrombosis

Summary

1. There is definite progress in the diagnosis,
technic and after results of surgery of the colon.

2. The early utilization of careful rectal,
proctoscopic and x-ray examinations will es-
tablish an earlier diagnosis, improve the opera-
bility, and reduce the frequency of acute ob-
struction.

3. The incidence of inflammatory lesions of
the colon is increasing.

4. Extensive pre-operative preparation is es-
sential.

5. The more frequent use of blood transfu-
sions is advocated.

6. The use of stage operations, radical resec-
tions and preference of the Mikulicz-Paul opera-
tion over primary anastomosis, is advised.

7. The technic of postoperative care, with
especial reference to the care of the colostomy,
is described.

8. A tabulated resume is given of our last
series of one hundred colon cases.

INDUSTRIAL HYGIENE

The University of Michigan takes pleasure in an-
nouncing its Second Annual Conference on Industrial
Hygiene to be held Thursday, Friday, and Saturday,
January 23, 24 and 25, 1941, in the Amphitheater, Horace
H. Rackham School of Graduate Studies. The purpose
of the Conference is to review the past year’s progress
in Industrial Hygiene and to point out and discuss some
of its trends. The Conference has in mind the
bringing out of the notion of the unity of industrial
hygiene including its personnel and activities and the
very close interrelationships of industrial hygiene to
the modern public health movement and to the health
sciences professions, with particular reference to the
medical profession.

The list of speakers includes representatives from
each of the special fields of industrial hygiene ; namely,
medicine, engineering, nursing and laboratory work.
The Conference should prove to be of interest and
value to physicians, engineers, dentists, nurses, public
health personal and industrial personnel managers. The
University of Michigan cordially invites members of
these professions to attend the Conference. No regis-
tration fees are stipulated.

28

20

13

5

6

5

4

2

4

4

1

3

2

1

1

1

75

1

1

1

1

2

1

4

2

1

1

25

19

44

34

57

41

31

29

29

28

21

19

18

17

11

9

6

46

Jour. M.S.M.S.

CLINICO-PATHOLOGICAL CONFERENCE

Clinica-Fathological

Conference

Wayne University College of Medicine

Paul H. Noth, M.S., M.D.

Assistant Professor of Medicine

Osborne A. Brines, B.S., M.D.

Associate Professor of Pathology

C. McD., white, female, aged fifty-six, Avas admitted
to the hospital September 21, complaining of jaundice
of seven months’ duration, recurrent attacks of abdomi-
nal pain and swelling of the same duration, and swell-
ing of the ankles of three Aveeks’ duration.

Present Illness. — The patient Avas Avell until about one
3'ear before admission AA'hen she began haA'ing a dull,
stead}', aching pain in the right sub-costal region an-
teriorly. This pain Avould come and go Avithout apparent
relation to meals, boAvel habits or exercise. About nine
months prior to admission she noted some sAvelling in
the abdomen Avhich lasted about a month and then sub-
sided. There Avere no other symptoms at this time ex-
cept for the dull, aching pain. About scA'en months ago
the patient had her first attack of colicky pain. This
Avas located chiefly just aboA'e the umbilicus on either
side of the mid-line, and radiated back to the tip of the
right scapula. It lasted about ten minutes, Avas seA'ere
enough to double the patient up and Avas accompanied
b}' nausea and A'omiting. She became jaundiced shortly
after this and also noted recurrence of the abdominal
SAvelling. The jaundice persisted for about seA^en AA'eeks
and then, according to the patient, completel}" disap-
peared. About a month folloAving this she had another
similar attack and since then she has been constantl}'
jaundiced to some extent, although the degree of jaun-
dice has fluctuated considerably. During these attacks
the urine aaus dark in color and the stools light. Sub-
sequentl}' there AA'as considerable A'ariation in the color
of the urine and stools. About three Aveeks before ad-
mission, the patient experienced the third attack of
severe, cramping abdominal pain Avhich Avas folloAved
by itching of the skin and also swelling of the ankles.
At this time there Avas an increase in the amount of
the SAA'elling of the abdomen. Throughout the illness
there had been a moderate amount of nausea and
bloating AA'ith intolerance to SAAeets, cabbage and fatty
foods. For the past two }'ears the patient had eaten
practically no meat because of the alleged presence of
hypertension. Her Aveight decreased from 237 pounds
to about 215 pounds AA'ith an increase to the original
AA'eight in the three AA'eeks preceding admission. Dur-
ing the six AA'eeks preceding admission there had
been noted droAvsiness and extreme fatigue. There Avas
no history of qualitatEe food distress, indigestion or
abdominal pain prior to the present illness. No historj'
of A'enereal disease, alcoholism or ingestion of anj'

type of medicine prior to the present illness. No cardio-
respiratory or genito-urinar}" symptoms.

Past History. — No seA'ere illnesses. No operations or
injuries. History by systems essentiall}^ negative except
for “high blood pressure” Avith a sj^stolic level said
b}' the patient to be 270 in 1936, accompanied by hot
flashes, fatigue and droAvsiness but unaccompanied b>'
edema, cough or appreciable dispnea. She Avas relieved
of these sj'mptoms after being placed on the Ioav pro-
tein diet. Menstrual historj' normal, Avith menopause at
age of 41.

Family History. — Mother and father died of pneu-
monia at the ages of fifty-eight and sevently-eight, re-
specttyely. Taa'O brothers and one sister living and well.
One sister died from a stroke at the age of fifty-tAA'o.
No historA' of cancer, tuberculosis or diabetes.

Marital History. — Married at thirty-eight, diA^orced at
forty. No pregnancies. Former husband Ih'ing and Avell.

Occupational History. — HouseAAork.

Physical Examination. — Revealed a Avell-deA'eloped,
obese, AA'hite female markedly icteric but in no apparent
distress. Temperature 98.2°, pulse 80, respirations 16.
The ocular pupils Avere equal and reacted to light and
upon accommodation. The fundi shoAved normal discs,
slight sclerosis and narroAA'ing of the retinal arterioles.
No hemorrhages or exudates. Examination of the ears,
nose, throat and neck negative. The lungs Avere clear.
The heart Avas of normal size. The cardiac rhythm AA'as
regular and the heart sounds of normal quality. There
AA'as a soft S3'stolic apichl murmur. The blood pressure
on several occasions varied between 154/97 and 122/80.
The abdomen Avas moderately distended AAuth shifting
dullness in the flanks. No palpable organs. There Avas
no costo-A'ertebral angle tenderness. There Avere several
purpuric spots in the skin of the abdominal Avail. There
Avas marked pitting edema of the loAver extremities. The
tendon reflexes AA'ere equal and acth'e.

Laboratory Tests on Admission

E*rinal3'sis — specific graA'ity 1.010, sugar 0, albumin 0,
WBC occasional. Blood: Hemoglobin 11.0 G., RBC
3.64 millions; Color Index 1.0. M’BC 10,500, Neutro-
phils 70 per cent (Filamented 62 per cent, Non-fila-
mented 8 per cent), Lymphoc3'tes 8 per cent. Eosino-
phils 2 per cent. Kline and Kahn positiA'e. Icteric in-
dex 60. Blood cholestrol 171 mg. per cent. Serum albu-
min 2.9 G. per cent; serum globulin 2.8 G. per cent.
Urine for urobilinogen — highest positKe dilution = 1-50.
Gastric analysis : free HCl 0. Total acidity varied from
4 to 8 degrees. No occult blood.

Subsequent Laboratory Tests. — E'rines for urobil :
(highest positive dilutions) 9/26 — 1-30; 9/27 — 1-70 ; 9/28
— 1-20; 9/29 — negative; 9/30 — negative; 10/2 — negative;
10/3 — ^negath'e; 10/4 — 1-50; 10/6 — negath'e. Subsequent
Urinalyses — specific graA'ity' A'aried from 1.010 to 1.020,
0 to trace of albumin. Urinar}' sediment (uncatheter-

J.A.NUARY, 1941

47

CLINICO-PATHOLOGICAL CONFERENCE

ized specimens) contained occasional to 50 WBC, ex-
cept on two occasions below 10. The last urinalysis was
obtained on 10/7. Icteric indices : 9/26 — 60 ; 9/30 — 53 ;
(van den Bergh direct immediate strong, bilirubin 4.4
mg. per cent) ; 10/19 — 48. Stool examination; 9/27 — uro-
bilin, occult blood 0. Blood ureas: 10/10 — 26; 10/20 —
32. Hippuric Acid Test : 9/27 — ^0.50 G. benzoic acid re-
covered. 10/6 — no hippuric acid precipitated. 10/5 — ga-
lactose tolerance test (40 G. galactose oral feeding)
2.47 G. recovered. 9/30 — serum phosphates 2.3 units,
serum phosphorus 5.2 mg. per cent. Repeat Kline — ^9/27
negative. Prothrombin times : 9/29 — ^25 seconds ; 10/3 —
42; 10/6-^; 10/10—25; 10/13— 32; 10/13 (5^ hours
after vitamin Ks) 34; 10/15 — (after second dose Ks)
25; 10/19 — 35; 10/20 — 31. (Normal prothrombin time
with method used is 13 seconds.) 10/16 — Ascitic fluid:
specific gravity 1.014, albumin 8.4 G/liter, total cells
190, WBC 56, 56 per cent lymphocytes, 44 per cent
polymorphonuclear. Some mesothelial cells.

Clinical Course

The patient’s temperature remained at normal levels,
except for a slight rise on 10/15 to 101°, until 10/20
when it rose to 102°, reaching the height of 103° on
10/21. The pulse rate ranged between 80 and 100 ex-
cept for the terminal rise. Respirations varied between
20 and 25 except for terminal rise to 35. During the
first part of her hospital stay the patient was eating
well and feeling quite well generally. She was placed
on a high carbohydrate, low fat diet which she took
without difficulty. On 9/29 bile salts and vitamin B
therapy was started. The patient received two cap-
sules of dessicated bile three times daily. Starting 9/29
one capsule napthoquinone (dry) three times daily.
10/4 napthoquinone in oil three capsules daily substi-
tuted. 10/13 — 4 mgs. vitamin Ks I.V. Starting 10/17
natural vitamin K eight capsules daily and 4 mgs.
vitamin Ks I.V. daily. On 10/10 it was noted that the
patient had become lethargic and disoriented. On 10/15
there was an increase in the amount of ascites and the
patient complained of considerable pain in the abdomen.
On 10/16 the abdominal paracentesis yielded about 1700
c.c. of slightly cloudy, straw colored, odorless fluid. On
10/20 the heart was found to be enlarged and the car-
diac sounds were of poor quality. In spite of digi-
talization the patient became progressively more drowsy
and weak and expired on 10/21.

Discussion

Dr. Douglas Donald. — There are a number
of significant facts in the history of this patient’s
illness.

One cannot be certain whether the abdomi-
nal distension noted early in the course of the
disease was due to ascites or to gaseous dis-
tension. The attacks of severe abdominal pains
are quite typical of biliary colic because of the
location and radiation of the pain and in spite

of the fact that they were of short duration.
The history of intolerance for fatty foods, the
occurrence of light stools and dark urine at
the times of the attacks of pain, the pruritus
and the fluctuation in the intensity of the jaun-
dice are all suggestive of obstructive jaundice
due to common duct stone.

The cause of the edema of the ankles which
occurred following the last attack of pain is
not clear. The extreme fatigue and tendency to
drowsiness are suggestive of the presence of
severe hepatic damage. In other cases of hepat-
ic insufficiency these toxic symptoms may be
replaced by mania or delirium. Their exact
etiology is unknown. The past history is not
remarkable except for the alleged presence of
a marked hypertension. In view of levels of
blood pressure noted during the patient’s hos-
pital stay and the absence of findings of car-
diac disease, I would be inclined to doubt the
correctness of this part of the histor}^ although
such fluctuations in blood pressure occur occa-
sionally.

The findings on physical examination do not
suggest that cardiac embarrassment was pres-
ent. The soft apical murmur in the absence of
other cardiac findings is not significant, and
is probably, in view of the anemia, a hemic
murmur. The other physical findings of ascites
and purpuric skin lesions indicate severe hepa-
tic damage, but like the right upper quadrant
tenderness, are of little value in the differen-
tial diagnosis between various etiologic types
of disease of the liver.

The initially positive Kline and Kahn tests
of the blood with later reversal to negative of
the Kline test must be evaluated cautiously in
the presence of jaundice which may produce
falsely positive tests. The subsequent negative
Kline test as well as the clinical picture makes
me feel that syphilis, if present, is not an im-
portant factor. The urobilinogen levels in the
urine fluctuated between a positive test in a
dilution of 1-70 and several negative tests. The
former reading is definitely indicative of hepat-
ic damage, and the periodic negative tests
probably indicate an intermittent biliary tract
obstruction. The finding of urobilinogen in the
stools excludes complete biliary tract obstruc-
tion with greater finality than the presence of
urobilinogen in the urine since, in some in-

48

Jour. M.S.M.S.

CLINICO-PATHOLOGICAL CONFERENCE

stances of complete biliary tract obstruction,
it is believed that the biliary pigment may be
converted into urobilinogen in infected dilated
biliary ducts, be absorbed and excreted in the
urine. The abnormal hippuric acid test and the
normal galactose tolerance test illustrate the
well-known fact that it is difficult to measure
the function of such a complex organ as the
liver which possesses such remarkable powers
of regeneration.

The patient’s down-hill clinical course is
most suggestive of increasing hepatic insuffi-
ciency. The evidence of cardiac failure which
appeared terminally are frequently obser^'ed
in similar cases and do not respond to digi-
talis therapy.

What shall we consider as possible diagnoses
in this case? The types of extra-hepatic ob-
structive jaundice which should be mentioned
are those due to choledocholithiasis, carcinoma
of the bile ducts, or carcinoma of the pancreas ;
the types of intra-hepatic jaundice which
should be mentioned are toxic hepatitis, in-
fectious hepatitis, cirrhosis of the liver and
diffuse involvement of the liver by primary or
metastatic carcinoma.

Of those possibilities, choledocholithiasis
best explains the history of biliary colic, the
intermittency of the jaimdice, and the appear-
ance and disappearance of urobilinogen in the
urine. The latter tw’O findings are seldom seen
in carcinoma of the pancreas or bile ducts in
which the jaundice is usually persistent, and
the disappearance of urobilinogen from the
urine is usually not followed by its reappear-
ance. The evidences of severe hepatic damage
seen in this case, namely the ascites, purpura,
and drowsiness, and the long course of the ill-
ness make me feel that in addition to the ob-
structive jaundice caused by a common duct
stone there is present also a secondary biliary
cirrhosis.

Dr. Edward D. Spalding. — I agree with Dr.
Donald’s diagnosis of the chief diseases pres-
ent. I would like to emphasize the probability
that this patient had in addition hypertensive
cardiovascular disease. A woman who weighed
237 pounds, and had a history of hypertension
is not likely to have a normal cardiovascular

system and the findings of ascites, peripheral
edema, and terminal enlargement of the heart
all could be interpreted as indicating the pres-
ence of hypertensive heart disease with cardiac
failure.

If digitalization was going to be instituted
it would have been more helpful to do so be-
fore the terminal stage. It would also seem to
me that as judged by this case summary, too
much attention was paid to vitamin K and
not enough to the danger of too great delay
in operation which, if performed at the time
the patient was doing well, might have stem-
med the tide which carried her along to exitus.

Dr. Saul Rosexzweig. — The two previous
discussants have made out a very good case for
the presence of a common duct stone to explain
the jaundice which this patient had. I agree with
Dr. Donald that she had in addition severe hepat-
ic damage as the cause of the edema and ascites
which were present. The long intermittent course
is an ideal set-up for the development of a
chronic cholangitis with a resulting biliary cir-
rhosis. The alleged previous severe hypertension
might have been due to nephritis, and occasion-
ally one sees a patient who has severe liver
damage in whom autopsy reveals the primary
cause to be the renal pathology. However, in this
case my diagnosis corresponds with that of Dr.
Donald.

Dr. Robert Schneck. — I don’t see how we
can avoid a diagnosis of common duct stone in
this case. I also agree that this patient had cir-
rhosis of the liver. I don’t think we can say that
this is entirely secondary to the gall-bladder
disease because of the early occurrence of ascites
and the absence of fever. Further, patients with
biliar}' cirrhosis have large livers whereas this
patient had a small liver. Therefore, I believe
that a double diagnosis of portal cirrhosis and
common duct stone is the correct one.

Dr. Sol Meyers. — The histor}' of biliary colic
seems quite definite in this case, but the subse-
quent course of events is not entirely clear.

The occurrence of swelling of the abdomen
presumably due to ascites soon after the attack
of colic is not what one would expect to occur

Janu.\ry, 1941

49

CLINICO-PATHOLOGICAL CONFERENCE

immediately after the impaction of a stone
in the common duct. Biliary cirrhosis frequent-
ly occurs in patients with calculous biliary
tract obstruction and may then produce all the
findings seen in advanced portal cirrhosis such
as ascites, anemia, or drowsiness. However, it
does not develop with sufficient rapidity so
that it can be considered as the cause of the
ascites in this case.

Further, as Dr. Spalding has pointed out, it
is unusual for these patients to be afebrile as this
patient was for about three weeks of her hos-
pital stay. There is usually an associated cholan-
gitis which, if it does not cause the typical re-
current chills, at least causes some fever. Biliary
cirrhosis is divided into two types, the primary
or so-called Hanot’s cirrhosis and the secondary
or Charcot’s cirrhosis. The former is character-
ized by a large liver, large spleen, jaundice and
paroxysms of fever accompanied by leukocytosis
occurring usually in a younger individual. Cer-
tainly that is not the picture here. The Charcot
type is usually characterized by the presence of
recurrent chills and fever, a chronic jaundice
which fluctuates in intensity, varying degrees of
enlargement of the liver frequently not associated
with splenomegaly, and leukocytosis.

In this case because of the early appearance
of ascites and the absence of fever and leuko-
cytosis it is questionable whether we can be
safe in assuming that a secondary biliary cir-
rhosis is present. Therefore, we must consider
other types of hepatic disease.

Malignancy of the liver, either primary or
secondary, is unlikely because of the presence
of obesity, and the fluctuation in two impor-
tant symptoms : namely, swelling of the ab-
domen, and jaundice. Portal cirrhosis is an un-
likely possibility because of the presence of
severe colicy pain and the early appearance
of jaundice. Syphilitic cirrhosis is also a pos-
sibility but there are no conclusive evidences
of its presence ; that is, the serologic tests are
contradictory, there is no other evidence of
syphilis, and the shape of the liver is not
grossly nodular as one would find in a hepar
lobatum. Also the rapid downhill course is not
usually seen in syphilis of the liver, and the ab-

sence of splenomegaly is another point against
it.

^ In the condition called mixed cirrhosis we
can get the picture described by this patient’s
illness. Involvement of the portal system,
similar to that seen in ordinary portal cirrhosis
and responsible for the ascites, is combined
with involvement of the biliary duct system in
the liver and is the cause of jaundice.

This explains the co-existence of recurrent
jaundice with evidence of portal obstruction
such as ascites. This really amounts to a
double diagnosis, but I believe it is the most
likely one in this case. I realize that only a
small fraction of patients with cirrhosis of the
liver have biliary colic. On the other hand I
have seen patients with typical biliary colic in
whom no stones were found.

Dr. a. Hazen Price. — The history of the ab-
dominal pain which this patient experienced is
suggestive of biliary colic, but could well, es-
pecially in view of its short duration, be due
to pylorospasm. With this in mind I believe
that all the various findings in this patient’s
history and examination are best explained by
a chronic hepatitis with jaundice. It is stated
that she felt quite well during the first part
of her hospital stay, and therefore, it may be
considered that she took a sudden turn for the
worse and went down-hill rapidly after that.

I am inclined to feel that this was a cardiac
death, possibly due to coronary thrombosis.

Roentgenologic Findings

(Reported after clinical discussion)

A flat plate of the gall-bladder area showed no evi-
dence of opaque calculus. A gastro-intestinal series
showed that the stomach filled well, revealing no de-
fects in the gastric outline. There was evidence of
pressure on the upper one-third of the stomach from
the splenic area. The duodenum was visualized show-
ing no irregularities in contour. There was no dis-
placement of the duodenal looping. The stomach was
empty at five hours with the head of the meal in the
caecum. Twenty-four hour examination was negative.

Pathologic Findings

Final Diagnosis. — (D subacute yellow atrophy of the
liver; (2) splenomegaly; (3) anasarca; (4) bile ne-
phrosis; (5) myocardosis; (6) obesity; (7) fatt}’ atro-
phy of the pancreas.

50

Jour. M.S.M.S.

CLINICO-PATHOLOGICAL CONFERENCE

Toxic hepatitis might be substituted for the first
diagnosis. The basic pathology is necrosis of the liver
occurring on a small scale over a considerable period
of time. The liver in this case weighed 1220 grams.
The surface was irregular due to numerous depressions,
alternated by elevations over the entire surface of both
lobes. In some places, however, the capsule was smooth.
The cut surface was yellow and the consistency soft.
There were obvious areas of regenerative hyperplasia.
The gall bladder and extra-hepatic biliary tract were
normal. In the liver sections there was no actual ne-
crosis. Evidences of severe parenchymal destruction
were present, however, in the form of areas of lobular
deficiency measuring from a few millimeters to several
centimeters in diameter in which only bile ducts re-
mained. In these areas there was infiltration of in-
flammatory cells, chiefly lymphocytes, and evidence of
repair consisting of capillary proliferation and con-
nective tissue production. At the edges of such areas,
the lobules were only partially destroyed. In another
area there was nodular reparative hyperplasia. In some
areas the parenchyma had remained intact.

The life history of such a lesion would be that
small areas of necrosis had been produced as a con-
tinuous or recurrent process over a considerable period
of time with enough functioning liver parenchyma be-
ing left intact to be compatible with life. This situ-
ation is in contrast to acute yellow atrophy where ne-
crosis is much more extensive and the clinical course
is only a few days. The progress of this patient’s
disease was much slower than in the average case of
subacute yellow atrophj^, the difference being wholly
one of severity or extensiveness of the necrosis. Had
necrosis ceased at any time, complete healing might have
occurred and the lesion known as toxic cirrhosis then
might have developed. The etiolog>^ in this case was
unknown but the patholog}"^ was more characteristic of
chemical than bacterial damage.

The spleen weighed 710 grams. H}-pertroph3" was
due to engorgement. The kidneys weighed 200 grams
each. There was considerable degeneration of the tu-
bular epithelium apparently due to cholemia. Anasarca
was evidently the result of hypoproteinemia. Sections
of myocardium showed considerable acute toxic de-
generation. Each pleural cavity was one-quarter filled
with clear straw-colored fluid. The heart weighed 450
grams. The peritoneal cavity contained between three
and four liters of transudate.

Dr. Paul H. Noth. — In retrospect there are
a few additional comments which should be
made concerning this case. While colicy pain
in the hepatic area is most characteristically
associated with cholelithiasis, it occurs ^o
frequently in carcinoma of the

The ineffectiveness of the large amounts of
potent vitamin K material in reducing the pro-
thrombin time in this case is noteworthy, and,
judged by our experience in similar cases of
chronic hepatitis is indicative of severe hepat-
ic damage. In most cases of obstructive jaun-
dice these amounts of vitamin K, particularly
^5 given intravenously, have resulted in a
prompt fall to normal or near-normal values
of the prothrombin time.

The explanation of this difference in re-
sponse is that in cases of obstructive jaundice
uncomplicated by severe hepatic damage the
defect in the clotting mechanism lies chiefly
in the lack of sufficient absorption of fat-solu-
ble vitamin K from the intestinal tract due to
partial or complete exclusion of bile which
is necessary for proper absorption of this and
other fat-soluble substances. On the other
hand in the presence of severe damage the
liver is largely unable to utilize vitamin K in
the formation of prothrombin even when it is
given parenterally. Therefore, in a sense, the
response of a patient’s prothrombin time to
vitamin K therapy is a test of liver function
having some value as an aid in differential
diagnosis between intrahepatic and obstructive
jaundice as well as being an index of the de-
gree of complicating hepatitis in patients hav-
ing known biliary tract obstruction.

SECOND ANNUAL CONFERENCE ON INDUSTRIAL
HYGIENE, ANN ARBOR, MICHIGAN

Partial Program

Thursday, Jamuiry 23 — Health Promotion in Indus-
try; Industrial Medicine and Qther Health Agencies;
Studies in Industrial Hygiene ; Comprehensive Industrial
Hygiene Investigations ; Occupational Diseases ; Indus-
trial Dermatoses ; Pathological Phases of Industrial
Diseases.

At the dinner meeting, J. J. Bloomfield, Industrial
Engineer, will speak on “Industrial H3^giene in the Na-
tional Defense Program.”

Friday, January 24 — Symposium on the Medical Serv-
ice in Industry; The Full-time Industrial Physician;
The Part-time Industrial Physician; The Physician in
Private Practice; Industrial Nursing Service; The Rela-
tion of the Industrial Hygienist to the Industrial Medi-
cal Service; Studies in Industrial Hygiene (continued) ;
Engineering Control of Industrial Hazards ; The Indus-
trial Health Laboratory; Industrial Legislation;

A special program by the students of the Division of
zgiene and Public Health, University of Michigan, will

gas YaQ(f at the dinner meeting.

. . . J. J- . 1 .U.I- ^^tpu^^y, January 25 — Studies in Industrial Hygiene

also in 'various forms of hepatltj^^,^ the Ia.tter . (conrifi;q^4 ; Industrial Relations; Development and

two diseases it is usually mild^^n degTj^_ ^^d r>^ctic^d!

less likely to radiate posteriorly,

Industrial Hygiene in State and Local
artments ; Section on Industrial Nursing;
Founded 1313 Section on [Industrial H3’giene Laboratory.

dir

'V,

OF

January, 1941

51

N.Y.A. Health Program

☆

National defense today is no longer a question of march-
ing men; it is a matter of vocational training for the main-
tenance of a complete defense program. In Michigan alone,
the National Youth Administration is training 30,000 unem-
ployed youths, between the ages of sixteen to twenty-four
years and out of school, in manipulative fields. These boys
and girls are becoming skilled workers with scores being
assimilated in industry every month.

A health examination program for these unemployed out-of-
school youths has been developed by the NYA and approved
by your State Society. Its objective is to provide a physi-
cal examination of all trainees ; also to assist in the
correction of remedial defects found by these examinations
by referring trainees to their family doctors. It is hoped that
through this introduction of the trainee to good medical prac-
tice, a desire for such service from his family physician will
be created and will last throughout his life.

To this end, members of county medical societies are in-
vited to cooperate with the National Youth Administration in
its carefully prepared Health Program. It is a practical plan
to bring needed health education and assistance to a neglected
group, at the most impressionable age of their lives. It is
the doctors’ opportunity to participate in this program, aimed
to help those being trained to productivity and economic re-
habilitation.

☆

President, Michigan State Medical Society

Jour. M.S.M.S.

-X EDITORIAL X-

Proposed Detroit Medical Center

DETROIT, A MAJOR MEDICAL CENTER

■ Michigan has appreciated the accomplish-
ments of Dean Norris of the Wayne Univer-
sity College of Medicine and his faculty in their
continued advance in medical education.

Now the vision of further advances is becom-
ing a reality.

The newspapers of the state have carried
the stor}^ of the new medical unit from the first
hope of Dean Norris, the active cooperation of
the Wayne County Medical Society, and the
necessary practical assistance of such men of
Knudson, Lescohier, Eamon, Marshall, McMath,
Keidan, Henry, and Martha C. Sheldon. The
Anderson family, showing the same foresight
and enthusiasm they showed in their initial sup-
port of Henry Ford, have proved vital factors

in advancing this far-reaching program. The
Common Council of Detroit lost no time in mak-
ing the necessary land available.

Already $8,000,000 has been subscribed (to
which almost every Detroit physician gave his
bit) and the plan is finally expected to enable
the construction of a $50,000,000 medical center
which will challenge the finest in the world. The
greatest cooperation has been obtained from
professional, political, and business as well as
philanthropic organizations and individuals.

It is hardly necessary to assure Dean Norris
and the physicians of Detroit that every practi-
tioner of Michigan rejoices with them in this
approaching fulfilment of their desire.

Janu.ary, 1941

53

EDITORIAL

DR. HOSPITAL?

■ What is a hospital? Of course, primarily

a hospital is a building in which nursing and
medical care may be given in a more efficient
manner than at home. Speaking bluntly, with-
out doctors there could be no hospitals. Yet to
a more or less increasing degree, the medical
profession, which is the most important part of
the hospital set-up, has been subjugated to play
a very minor role in determining the policies and
practical administration of the hospitals. This
is especially true in the larger centers.

A perusal of some recent literature seems to
establish that the hospital is extending its di-
rection to purely medical subjects. An excur-
sion into the realms of the possible extent of such
domination by the hospital boards over the medi-
cal profession would be classified as subversive
activities by some of these boards. Certainly,
the intrusion has increased markedly in the last
twenty years and if this is to continue there
will be as much obstruction to the private prac-
tice of medicine through this domination as
through political regimentation.

The solution is easy in theory but difficult in
practice. Insistence by the profession of its
inherent right to supervise and direct all purely
medical problems is essentially all that is neces-
sary. Some of the reasons why it is difficult
to establish this right may well be considered even
though they may not be entirely uncontroversial.

Most physicians agree that a closed staff is
fertile ground for spreading discord among the
profession. At least in many cases hospital
superintendents will play one staff member
against another in order to persuade them into
relinquishing some of their inherent rights. One
very well known physician stated not long ago
that he had to take certain orders of a strictly
professional matter from the superintendent of
his hospital because if he refused he would
be forced to resign and there were ten others
ready to step into his place. He realized that
maintaining his practice depended to a consid-
erable extent upon the legitimate “advertising”
which his position automatically gave him.

It is well known that in those districts in
which the physicians have insisted upon open
staffs, and fought valiantly to retain the ad-
ministration of medical problems through their
county medical society, division of medical forces
has not been possible and the profession has

maintained its leadership in medical problems.

Another dangerous precedent is in allowing
the appointment of the staff by the superintend-
ent and his governing lay board. It seems un-
contradictable that the profession should be able
to select its medical leaders more intelligently than
a lay board.

Another highly explosive factor is the free
and the part-pay clinic. It is safe to say that
in most instances the physician who is, after all,
the one indispensable factor in providing the
service has absolutely no control over what pa-
tients may be included, and often but little con-
trol over what the treatment should be.

Perhaps the solution is too complex for a
local or state movement and it may be that the
American Medical Association will be forced into
promulgating some definitely constructed prin-
ciples regarding the rights and privileges of the
physician in the hospital.

The trend is dangerous and many besides the
alarmists feel it has already reached a serious
state.

THE PLATFORM OF THE AMERICAN
MEDICAL ASSOCIATION

The American Medical Association advocates:

1. The establishment of an agency of federal
government under which shall be coordinated and
administered all medical and health functions of the
federal government exclusive of those of the Army
and Navy.

2. The allotment of such funds as the Congress
may make available to any state in actual need for
the prevention of disease, the promotion of health
and the care of the sick on proof of such need.

3. The principle that the care of the public health
and the provision of medical service to the sick is
primarily a local responsibility.

4. The development of a mechanism for meet-
ing the needs of expansion of preventive medical
services with local determination of needs and local
control of administration.

5. The extension of medical care for the indigent
and the medically indigent with local determination
of needs and local control of administration.

6. In the extension of medical services to all the
people, the utmost utilization of qualified medical
and hospital facilities already established.

7. The continued development of the private
practice of medicine, subject to such changes as may
be necessary to maintain the quality of medical serv-
ices and to increase their availability.

8. Expansion of public health and medical serv-
ices consistent with the American system of democ-
racy.

54

Jour. M.S.M.S.

MICHIGAN MEDICAL SERVICE

One Year of Op>eration Nears

■ February 28 of the New Year 1941 will mark

the completion of the first year of operation
for Michigan Medical Service. In retrospect, the
past year will be outstanding because of the
launching of the first voluntary prepayment med-
ical service plan organized under a special en-
abling act and sponsored by the medical pro-
fession.

The organizing, financing, and operation of
this medical service program by the doctors of
Michigan has set a precedent for the rest of
the United States to follow. Medical service
plans were in operation on the Pacific Coast and
in Canada prior to Michigan Aledical Service,
but the Michigan plan has paved the way in the
development of a medical plan under a special
governing law and in the formation of a low-
cost Surgical Benefit Plan.

The growth of prepayment medical service
plans sponsored by medical societies is indicated
by the development of such programs in 21 states.
Already 29 medical service plans sponsored by
medical societies are in operation.

Continued Cooperation Needed

At the start of the New Year, it is appropriate
to re-emphasize that each individual doctor has
to take his share of the responsibility for a suc-
cessful administration of the medical service pro-
gram. The Board of Directors, the committees,
and the officers in charge of the immediate con-
duct of the medical plan must have continuous
sympathetic cooperation from every doctor who
renders services for subscribers.

The proper functioning of the medical serv-
ice plan, especially for new groups of subscrib-
ers, depends on the effort each doctor takes to
make the first experience for the patient as a sub-
scriber a satisfactory occasion. Subscribers to
Michigan Medical Service are undertaking the
responsibility to pay monthly in advance for
medical services, in order that they may be as-
sured of such services when needed ; and further
that prompt payments will be available for the
doctor. For these mutual advantages to become
realities, it is necessaiy^ for the doctor to give
attention to the essential procedures, such as the
following ;

1. Identifkation of Subscribers. — The enroll-
ment of new groups of subscribers each month

by Michigan Medical Service means that doctors
may constantly expect patients who are sub-
scribers. Therefore, office secretaries should be
instructed to ask the patient whether he is a
subscriber to Michigan Medical Service and to
record his certificate number and the exact spell-
ing of his name from the Identification Card.
Observance of this procedure will facilitate au-
thorization for payment of Monthly Service Re-
port bills for services.

Two Types of Sersice

2. Determination of Services. — The doctor
must know the services to which the subscriber
is entitled under the medical service plan, in
order that proper arrangements may be made
with the patient. The new Identification Cards
carry Serv-ice No. 2 or 2 to designate the type
of seiA'ices.

Service No. 2 indicates that the subscriber is
enrolled in the complete iMedical Service Plan
and is entitled to both medical and surgical care
in the home, office, and hospital according to the
provisions of the Medical Service Certificate.

Service Do. 2 indicates that the subscriber is
enrolled in the Surgical Benefit Plan and is en-
titled to sugical, x-ray and maternity services
according to the provisions of the Surgical Bene-
fit Certificate, performed when the subscriber is
a bed patient in a hospital.

(Service No. 1 alone indicates that the patient
is a subscriber to the hospital service plan of
Michigan Hospital Service. iMost subscribers
will have a combination of services No. 1 and 2
or 1 and 3).

If there is any doubt in the doctor’s mind as
to whether or not the services required are bene-
fits under Michigan Medical Service, the Initial
Service Report setting forth the services to be
rendered will bring a prompt notice from Michi-
gan Medical Service whenever services requested
are not properly benefits under the subscriber’s
certificate.

Render BiUs Every Month

3. Monthly Service Bill. — At the completion
of services, but not later than the end of each
month, the doctor sends a Monthly Service Re-
port to the attention of the iMedical Advisor}^
Board itemizing the services rendered, which
are to be paid by Michigan iMedical Service.

January, 1941

55

MICHIGAN MEDICAL SERVICE

To avoid delay in the approval of this bill
for services, all information requested should be
filled in as completely as possible. The Medical
Advisory Board will be assisted greatly if the
doctor sending the report will indicate the amount
of special services he has rendered such as the
extent of lacerations sutured ; the location, size
and type of tumor or cyst removed ; the partic-
ular type of operation performed (Sturmdorf,
Baldy -Webster, Caldwell-Luc, etc.). Each serv-
ice is paid for separately ; hence, it is important
to specify all services rendered.

A revised Monthly Service Report embody-
ing many improvements gained by actual experi-
ence is now ready for use and will make re-
porting even more simple for the doctor.

One of the chief problems in the first several
months of operation of Michigan Medical Serv-
ice has been the failure on the part of doctors
to send Monthly Service Reports promptly (once
per month) or to send completed reports. Such
late or incomplete reports make it impossible
to pay doctors promptly. It will be to the ad-
vantage of all concerned — the patient, the doc-
tor, and the medical service plan — if the doctor
and his office assistant will give close attention
to rendering prompt and complete bills to Michi-
gan Medical Service for services rendered.

After the completed Monthly Service Report
is sent to Michigan Medical Service, the doctor
should make certain that a bill is not also sent
by his office to the patient. The sending of a
bill to the patient causes confusion. If the pa-
tient is a subscriber to Michigan Medical Service
with an income below the limit of $2,000 for the
Individual Certificate or $2,500 for the Husband
and Wife or Family Certificate, no bill should
be sent by the doctor to the patient for services
which are to be paid in full by Michigan Medical
Service. However, in the event the patient is
a subscriber whose income is above the limit, the
statement which is returned with the check by
Michigan Medical Service will indicate that the
payment is to apply as a credit. The doctor
may then send a bill to the patient for the dif-
ference, if any, between the payment received
from Michigan Medical Service and the charge
which we would customarily make to the patient.

Payments Determined by Doctors

Attention is invited to the important fact that
the payments to be authorized for services are

56

determined by the doctors themselves. Any in-
equity in the payments made can be rectified by
presentation of the matter to the Medical Advis-
ory Board. No outside party or insurance com-
pany is arbitrarily deciding the payments that
should be made for services rendered.

Payments to doctors are made in accordance
with each service rendered. Therefore, it is of
considerable importance for the doctor to specify
in his Monthly Service Report each service ren-
dered in order that the Medical Advisory Board
can authorize payment. For example, if in the
course of the office treatment the doctor orders
blood examinations, a basal metabolism test, or
similar services, all such services should be item-
ized in order that the appropriate payment for
each can be made.

A Schedule of Benefits, which has been pre-
pared with the cooperation of numerous commit-
tees representing the Michigan State Medical So-
ciety and the various specialty groups, is used by
the Medical Advisory Boards as a guide in the
determination of the payment to be authorized.

The items in the Schedule are equivalent to
the prevailing charges by doctors of medicine in
Michigan for services to subscribers in the in-
come group below $2,000 per year for an indi-
vidual and $2,500 per year for a family. Pay-
ments for all Monthly Service Reports are au-
thorized in accordance with the level of benefits
indicated in the Schedule. In cases where ex-
tensive services or prolonged aftercare is re-
quired, extra payments in addition to the Sched-
ule of Benefits are authorized.

Prompt Payments Up to You

Payments can be made promptly only for
Monthly Service Reports which are received on
time. Incomplete or late reports must wait until
the next meeting of the Medical Advisor)' Board
and accordingly payment is delayed.

Avoid delay in payment for your services by
sending a completed Monthly Service Report on
time.

To permit even more prompt payment to doc-
tors, the Board of Directors has authorized pay-
ments to doctors on a weekly, instead of a month-
ly, basis. This payment arrangement, which will
be put into operation as soon as possible, means
that payments can be made as soon as completed
reports are received and approved. Hence, doc-
tors should send in their Monthly Service Reports
immediately after services are completed.

louR. M.S.M.S.

>f YOU AND YOUR BUSINESS ><-

INTANGIBLES TAX AND ACCOUNTS
RECEIVABLE

A physician writes : “Many accounts receiv-
able are probably uncollectible, but this fact is
not definitely known at the time of the tax re-
turn. Is the Intangibles Tax payable on these
accounts ?”

The answer, according to the State Tax Com-
mission, is “yes.” The Commission, charged
with the administration of the 1939 Intangibles
Tax Law, has ruled that “until there has been
an actual bona fide charge-off or treatment of
the account or note by the taxpayer as worthless,
it should be shown in the return and the tax
computed thereon on the full face amount of
the account, regardless of the fact that its col-
lection may be known to be questionable. In
other words, notes and accounts receivable, for
the purposes of this tax, are either wholly good
or wholly bad so as to be in effect non-existent.”

Another question was asked “Is the tax pay-
able year after year on the same account?”

The answer again is “yes.” The State Tax
Commission holds that as long as an account is
carried on the books as a receivable, it is con-
sidered an asset and is held subject to the In-
tangibles tax !

“If accounts receivable are not collected, how
long must they remain on the books before they
are legally uncollectible ?” is another query asked.

The Statute of Limitations in Michigan out-
laws all open accounts and notes after they have
been inactive for a period of six years. In other
words, an account upon which no charge or
payment has been made for six years is con-
sidered uncollectible by the laws of the State of
Michigan. All accounts in this category naturally
should not be included when reporting Intangibles
Tax.

The State Tax Commission has established
the date of September 30, 1940, as the date for
obtaining the average value of bank deposits,
notes receivable, accounts receivable and other
similar credits whether or not secured, and notes
and accounts payable, the value of which changes
during the year, which date may be used in de-
termining the Intangibles Tax with respect to the

accounts directly connected with the conduct of
a particular business or professional practice.
All other holdings must be averaged for the
entire year.

County Secretaries Conference
Lansing, Sunday, January 19

THE RIGHT AND WRONG WAY

When the Legislature passes a law relating to
the practice of medicine, you as a physician know
pretty well what the effect of that law will be.
But experience has shown that members of the
Legislature do not always know how and why
their legislative acts will affect the practice of
medicine unless physicians write and tell them,
according to the Medical Society of the State
of New York.

Your views are always welcome, for the men
who stay in the Legislature the longest are those
who read and heed their constituents’ letters.
But there’s a right way to write effectively to
your legislators. May we offer these suggestions :

Do — spell your legislator’s name correctly ;
make sure whether he is a Senator or a Repre-
sentative ; state concisely what you think and
why — the briefer the better; cite specific illus-
trations, whenever possible, as to effects proposed
legislation would have on the practice of medi-
cine and people in your community ; write on
your office stationery; sign your name plainly.
Type it under the signature ; send a letter rather
than a telegram when time permits ; seize every
opportunity to become personally acquainted
with your legislators.

Don’t — threaten political reprisals ; don’t write
in a captious or belligerent mood ; don’t remind
your legislators of broken promises ; don’t at-
tempt to speak for anybody but yourself ; don’t
insert newspaper clippings or mimeograph ma-
terial ; don’t send a chain letter or post card ;
don’t quote from form letters ; don’t write only
when you want a favor. Letters of commenda-
tion are always welcome ; don’t try to make an
errand boy out of your legislator ; don’t become
a chronic letter writer.

January, 1941

57

YOU AND YOUR BUSINESS

HONORARY AND ASSOCIATE
MEMBERSHIPS FOR LAYMEN

At its 1940 session, the M.S.M.S. House of
Delegates amended the Constitution of the Michi-
gan State Medical Society so that county medical
societies may confer Honorary or Associate
Memberships on laymen. The section relating
to Honorary Membership states that “county
societies may elect any persons distinguished
for their services or attainments in Medicine or
the allied sciences, or other services of unusual
value to organized medicine or the medical pro-
fession.”

County Societies may elect as Associate Mem-
bers :

Persons not members of the profession but en-
gaged in scientific or professional pursuits whose prin-
ciples and ethics are consonant with those of this
Society.

“2. Internes serving their first year in any approved
hospital, internes of longer standing, resident physi-
cians in training, and teaching fellows not engaged
in private practice, but not after five years from the
receipt of first medical degree (M.D. or M.B.).

“3. Commissioned medical officers of the United
States Army, Navy, Public Health Service and Vet-
erans’ Administration on duty in this state who are
not engaged in private practice of medicine.

“4. Physicians not engaging in any phase of medi-
cal practice.”

Upon recommendation of a county society,
the M.S.M.S. House of Delegates may elect such
persons as Honorary or as Associate Members
of the State Society, according to Article Three,
Sections 4 and 5 of the M.S.M.S. Constitution.

County Secretaries Conference
Lansing, Sunday, lanuary 19

UABILITY OF A CITY-
EMPLOYED PHYSICIAN

It is well settled that a municipality is not
liable for the negligence of an employee engaged
in the care of the poor (Summers vs. Daviess
County, 103 Indiana, 262, 2 N.E. 725),

Conversely, therefore, the fact that a physician
may be employed by a city does not excuse him
from liability for injuries occasioned by his own
negligence. In the absence of a statute to the
contrary, a municipality may not be held liable
for injuries received by a welfare patient due to
the negligence of a physician employed by the
municipality. Ordinarily, the liability of the agent

is the liability of the principal ; but a principal
may escape liability in certain instances, even
though the agent remains liable, as where the
principal is acting purely in the performance of
a public duty.

County Secretaries Conference
Lansing, Sunday, lanuary 19

PRIVILEGED COMMUNICATIONS

“It is well recognized that medical records as
well as roentgenograms carry with them the
status of privileged communications unless the
patient expressly waives his rights in that re-
spect, or they have been negatived by law for
purposes of public policy. This, of course, im-
plies that notwithstanding that those possessing
such property hold the legal title thereto, they
are viewed as constructive trustees for the pa-
tient in that they are precluded from using such
property unconditionally for purposes which may
possibly run counter to the patient’s beneficial
equitable interests therein — without his consent,
or operation of the law.”

— Carl Scheffel, Medical Jurisprudence.

County Secretaries Conference
Lansing, Sunday, lanuary 19

"EVERY ELIGIBLE PHYSICIAN"

Each county society shall have general direc-
tion of the affairs of the profession in the county,
and its influence shall be constantly exerted for
bettering the scientific, the moral and material
conditions of every physician in the county;
systematic effort shall be made by each member
and by the county society as a whole to increase
the membership until it embraces everv eligible
physician in the county. (Erom M.S.IM.S. By-
laws, Chapter 9, Section 7).

LAWS AFFECTING DOCTORS

“Every law that is proposed, certainly every
law that is passed, and every law which may ad-
versely aft'ect him, whether or not it appears to
be directly connected with his professional ac-
tivities, ought to be viewed with keen interest
by every physician, and dealt with in an appro-
priate manner,” according to Carl Scheffel in his
Medical Jurisprudence, a worth-while work of
medical-legal questions.

58

louR. M.S.M.S.

YOU AND YOUR BUSINESS

KEEPING COMPLETE WRITTEN RECORDS

Leo M. Ford, J.D.

It is highly important that maximum care be
exerted in the keeping of complete and accurate
records. This is true from both the legal and
medical point of view. A record is a summary
or abstract of the professional relationship from
the time the patient first came under the doctor’s
care until he was discharged.

The making of the record and the examina-
tion of it from time to time while the patient
is under the doctor’s care, enables him to give
more careful attention to the important symp-
toms, the reaction to treatment, and undoubt-
edly leads to more accurate diagnosis and
treatment than is true when one relies on an
overtaxed memory.

From the legal point of view, a written record
establishes the dates of services, the diagnosis,
and the treatment. It is not possible to foresee
when this record may become important. One
case is as of much moment as another in this
regard, and carelessness or indifference in keep-
ing a written record only makes it easy for a
disgruntled patient to establish malpractice to the
satisfaction of a jury, when in fact the treatment
was proper.

For example, a case was recently filed against a
doctor who had no records. He reported that he had
never seen or treated the patient. He was so positive
that his memory was correct that on conditional exam-
ination before trial, he testified that he had never
treated the patient. The patient, however, was able
to establish by witnesses who accompanied him to the
office, that he had been under the doctor’s care and
had received treatment for the condition of which he
now complained. The doctor’s inability to recall the
patient, and his testimony that he never treated him,
made the defense practically hopeless.

It is, therefore, apparent for the doctor’s own
protection that accurate records be maintained.
A considerable duration of time, even years, may
elapse before they become of consequence.

In making a record of this character, which
shall be admissible as evidence should litiga-
tion develop, it is necessary that the entries be
made contemporaneously with the facts to
which the entries relate. But the term con-
temporaneous is not to be construed to mean
that the record must be made at the very
moment of the occurrence, although it should

be made as soon thereafter as would reason-
ably make it a part of the transaction.

In one case, the hospital record was offered
in evidence to show that the plaintiff, suing for
injuries sustained in an automobile accident, be-
haved in an unruly manner at the hospital while
under treatment and disobeyed the orders of
the doctor and the nurses as to keeping quiet and
refraining from movement which would likely
interfere with the proper adjustment and healing
of the fractured bones. From the evidence, it
was established that it was the rule of the hospi-
tal that a record should be kept, showing among
other things, the condition of the patient when
received, his treatment while in the institution,
his condition from time to time, denoting the
progress toward recovery or otherwise as the
case might be, and of such other matters as
might have a bearing upon the case. This record
was made up every three days, and the method
was the one employed at the hospital. It was
claimed by the plaintiff that the records were not
made contemporaneously and that they should
have been excluded, but the court took the oppo-
site view of the matter and held that taking into
consideration the regular method in which these
records were made, and the apparent impractica-
bility in a hospital of recording each event as it
occurred, the facts relating to the patient were
recorded within such reasonable time as would
make them a part of the transaction; therefore,
held them to be contemporaneous.

The court further held that the fact that the
recording officer made the entries embracing
some matters which did not come under his own
personal knowledge, but were communicated to
him through doctors and nurses connected with
the institution, did not affect the admissability of
the records. It has, however, been held in many
cases that such records, unless supported by the
testimony of the one who made them, if that
person is alive and capable of being produced
to testify, are not admissable.

Has the Patient a Right to His Case Record?

An interesting decision was recently handed
down on the question as to whether the patient
has a right to his case record. The patient had
been admitted to a private sanatorium for treat-
ment for an intoxication caused by a hypnotic.
The treatment had been successful, but the
patient desired to file suit against the manufac-

January, 1941

S9

YOU AND YOUR BUSINESS

turer of the drug used. To strengthen his alle-
gation in the declaration, he wished to make use
of the clinical history of his illness and requested
the attending physician to furnish him this rec-
ord. The doctor and the sanatorium denied his
request, and the patient brought legal action
against both, demanding the delivery of the
record. The defense contended that the history
of the patient is in the nature of the attending
physician’s private notations, intended solely for
his private use, and that such record should never
be accessible to a patient, and if the patient de-
sired to sue the pharmaceutical company, he
could have the members of the sanatorium stai¥
subpoenaed to be witnesses. The medical
experts who testified in this case were of the
opinion that case records were to be regarded as
a physician’s personal property and that under
no circumstances should a patient be permitted
access to them, and, further, that a universally
recognized principle of professional ethics for-
bids the physician to furnish the patient full
information on the latter’s physical condition
if such information might upset the patient’s
mental equilibrium. It must therefore remain
within the discretion of the physician whether he
wishes to supply a patient with his case history.

On the basis of the expert opinion, the Su-
preme Court dismissed the case.

The court specifically stated that a patient
has no right to demand access to the record
of his case if the physician considers the divulg-
ence of the data therein contained contra-indi-
cated. There exists, accordingly, no legal ave-
nue by which the plaintiff may become ac-
quainted with the etiology and the clinical
course of his malady.

Should suit be filed against the pharmaceutical
manufacturer, the court itself may impound med-
ical records for its own guidance, but the re-
linquishment of the medical records cannot be
legally claimed by private persons.

Privileged Communications

At common law, a physician was obliged to
disclose information acquired in his profession-
al capacity, if called upon by the court to do so.
There are now, in a great many jurisdictions,
statutes protecting the individual from such dis-
closures. This brings us to the question of
whether or not hospital records are privileged
communications in those states where privileged

statutes exist. The question as to the admis-
sability of hospital records was before the court
for adjudication in a suit for damages against a
municipality for personal injuries occasioned by
a defective sewer hole. The plaintiff, a woman,
claimed that the amputation of one of her legs
was the direct consequence of the accident. It
was admitted that four or five years before this,
she had fallen while skating and had trouble
with the leg which was amputated after the
accident at the sewer hole, and the records of
the hospital at which she was treated, both before
and after the accident, were offered as evidence
at the trial.

The doctor in charge of the records identified
the record as being the official record of the
hospital and offered it in evidence. The offer
of this evidence was excluded because the ent-
ries made were privileged communications,
first having been made for the attending phy-
sician in order that he might correctly diag-
nose the patient’s case and administer proper
treatment. The Supreme Court held this rul-
ing correct, as hospital physicians who treat
patients at a hospital cannot testify as to what
they learned while attending there. The
plaintiff contended that these records were not
privileged, since they were copies of the official
record, but the court held that it still remained
privileged. The court further held that the
mere fact that the ordinance of the city in
question required such a record kept, was no
reason why the statute regarding privileged
communications should be violated. The priv-
ilege statute, of course, obtains to individual
physician’s records just the same as to hospital
records.

Conclusion

To urge the keeping of accurate written rec-
ords is an old story, yet the protection afforded
by a detailed office record is often lost sight of
by the busy doctor. Time given to this detail
is far better than time given to defending a law
suit and disclosing to the public a careless and
indifferent practice. You need not make this
burdensome, but be meticulous in jotting down
each date with a note as to the nature of the
services rendered, sufficient to refresh your mem-
ory at some later date, should it become neces-
sary. This will enable the doctor to make a
more careful study of the case and arrive at a

60

Jour. M.S.M.S.

YOU AND YOUR BUSINESS

proper diagnosis and treatment, and furthermore,
give the doctor real protection should litigation
develop.

1941 CONVENTION IN
GRAND RAPIDS

The Council, upon authority granted by the
House of Delegates, has chosen Grand Rapids
for the 1941 annual meeting of the Michigan
State Medical Society. The dates: Wednesday,

Thursday and Friday, September 17, 18, 19. The
House of Delegates will meet Tuesday, Sep-
tember 16, 1941. The headquarters hotel will
be the Pantlind; the general assemblies, five sec-
tion meetings and the scientific and technical
exhibits will be housed in the Civic Auditorium.

County Secretaries Conference
Lansing, Sunday, January 19

USE THE TITLE "M.D."

The title “Doctor” is used, legally and other-
wise, by so many people in so many callings that
it is no longer descriptive of a Doctor of Medi-
cine. Only by using “M.D.” after his name on
his stationery, his prescription pads, and his sign,
can a Doctor of Medicine protect himself and
his patients from misrepresentation, inspired or
accidental.

It is further urged that Doctors of Medicine
who know of violations of the law regarding the
use of the unqualified title “Doctor” should notify
the State Department of Health — State Board of
Registration in Medicine of such irregularities.

THIRD ANNUAL FORUM ON ALLERGY

In response to an apparent demand, the Annual Forum
on Allergy was founded three j^ears ago by a group
of outstanding allergists in the middle west to afford
a forum in which to review the progress of Clinical
Allergy. Annual meetings have been held in Toledo,
Ohio, and Chicago, Illinois. This year the meeting will
be held at the Claypool Hotel in Indianapolis on Satur-
day and Sunday, January 11 and 12, 1941. This offers
to the internist, the pediatrician, the dermatologist, the
otolaryngologists, and all other physicians an oppor-
tunity to bring themselves up to date in this field of
medicine over a single week-end. All physicians in
good standing in their local medical society are most
welcome. There will be a small registration fee of five
dollars.

Program

SATURDAY, JANUARY 11, 1941
9:00-11 :00 a.m.

Registration at the Forum Headquarters Suite. This offers two
hours of informal discussion.

11:00-12:30 p.m.

STUDY GROUPS— Series A. Note attendance requires pre-
Forum registrations. Registrations should be mailed to
Dr. Tell Xelson, 636 Church Street, Evanston, Illinois.

Topics Instructors

1. Atopic Eczema Dr. Karl Figley, Toledo, Ohio

2. Urticaria... Dr. Ethan Allen Brown, Boston

3. Symptomatic Treatment in the Case
of Bronchial Asthma in Which Cause

Cannot Be Determined Dr. Milton Cohen, Cleveland

4. Mold Allergy Dr. S. M. Feinberg, Chicago

5. Allergic Coryza Dr. French Hansel, St. Louis

12:30 — Subscription Luncheon

2 :00-3 :00 p.m.

STUDY GROUPS— Series B

1. Atopic Eczema Dr. Rudolph Hecht, Chicago

2. Urticaria Dr. Jonathan Forman, Columbus

3. Symptomatic Treatment in the Case
of Bronchial Asthma in Which the

Cause Cannot Be Determined. .Dr. John Sheldon, Ann Arbor

4. Mold Allergy Dr. M. B. Morrow, Austin, Texas

Dr. Homer Prince, Houston, Texas

5. The Heart in Asthma. .Dr. Oscar Swineford, University, Va.

4:00 p.m.

SPECIAL LECTL^RE : Dr. George Waldbott, Detroit,
Presiding

Allergic Manifestations in the Eye
Dr. Albert D. Ruedemann, Cleveland Clinic

7 :00 p.m.

Annual Smoker with Informal Discussion and Demonstrations

Exhibits Demonstrators

(a) Ocular Allergy Dr. A. D. Rudemann, Cleveland

Dr. J. W. Themas, Cleveland

(b) Mold Allergy Association for Mycological Investigation

Dr. Marie Morrow, Austin, Texas
Dr. Homer Prince, Houston, Texas

(c) “Spontaneous Allergy^ (Atopy) in Lower

Animals’’ (Motion Picture) .. Dr. Fred Wittich, Minneapolis

SUNDAY, JANUARY 12, 1941
9:00-10:00 a.m.

SYMPOSIA ON CLINICAL SUBJECTS
Symposium on Bronchial Asthma
Moderator: Dr. B. Z. Rappaport, Chicago

The Importance of the Diaphragm in Bronchial Asthma

Dr. John Mitchell, Columbus, Ohio
The L’se of Breathing Exercises in the Treatment of Bronchial

Asthma Dr. I. M. Hinnant, Cleveland, Ohio

The Importance of Rest in the Treatment of Bronchial Asthma
Dr. Barney Credille, Flint, Michigan
The Importance of Nutrition in Bronchial Asthma

Dr. Howard Lee, Oshkosh, Wisconsin
QUESTION AND ANSWER PERIOD

10 :00-ll :00 a.m.

Symposium on Insects as Allergens
Moderator : Dr. Harry Huber, Chicago

Beetles Dr. Harvey Johnston, Ann Arbor, Michigan

Fish Food Dr. Karl Way, Akron, Ohio

Moths Dr. Ralph Mills, Decatur, Illinois

Grain Mites Dr. Fred Wittich, Minneapolis

QUESTION AND ANSWER PERIOD
11:00-12:00 noon

Symposium on Allergic Headache
Moderator : Dr. Theodore Squire, Milwaukee

Differential Diagnosis Dr. S. R. Zoss, Youngstown, Ohio

Value of Diagnostic Procedures

Dr. Myron Weitz, Cleveland, Ohio

Non-Specific Therapy Dr. E. G. Tatge, Evanston, Illinois

Specific Therapy Dr. Orville Withers, Kansas City, Missouri

QUESTION AND ANSWER PERIOD

12 :30 p.m.

ANNUAL FORUM DINNER
Dr. C. B. Bohner, Indianapolis, Presiding

The Presentation of Gold Medal for Distinguished and Out-
standing Contributions in the Field of Allergy.

2 :00 p.m.

THE ANNUAL FORUM LECTURE

Dr. Bela Schick, New York
Allergy, Hypersensitiveness and Immunity

SPECIAL LECTURE

Water and Electrolyte Metabolism in Allergy
Dr. M. M. Cook, St. Louis

J.\NUARY, 1941

61

-K Woman’s Auxiliary ~K

?

PRESIDENT'S MESSAGE

T T is with the feeling of deepest humility that I w'rite this, the President’s ^vlessage. I
J- appreciate to the fullest degree the confidence which you have shown in electing me, and

hope that I may be successful enough in this office to make you feel that your confidence

has not been misplaced. However, I can do nothing, without the help
of all of you. So let’s all put our shoulders to the wheel, and make
this an outstanding year for the Woman’s Auxiliary to the Michigan
State Medical Society !

There are several things which we hope to accomplish this year. In

the first place, I hope that Michigan will do what our national presi-

dent, Mrs. V. E. Holcombe, asked, and support the Bulletin. When
Airs. Holcombe was in Detroit for the meeting of the Woman’s

Auxiliary to the Alichigan State Aledical Society in September, she

stressed the fact that she was anxious to have as many Auxiliary
members as possible take the Bulletin. This is the official magazine
of the Woman’s Auxiliary to the American Medical Association, and
as such should be supported. An understanding of the affairs of the
National Auxiliary will add greatly to one’s interest in the County and
State Auxiliaries, and will make all members realize to what a far-
reaching organization they belong.

This year, with so much of the world at war, it seems to me particularly fitting that
we, as doctors’ wives, should do our utmost to alleviate suffering. There is Red Cross
work to be done everywhere, and if some of the County Auxiliaries are too small to organize

a unit for making bandages, let me urge you to at least offer to knit or sew. Let’s make

other women’s organizations realize that the medical auxiliaries are groups upon which they
can always count when there is an emergency.

There are many other things which we hope to accomplish this year, too. We hope to
organize more county auxiliaries, so that doctors’ wives may be banded together in all parts
of the state.

As to Public Relations, the task of seeing that correct medical information is presented
to the public is most important. If every County Auxiliary will do its utmost to have some-
thing constructive along this line to report, Michigan will have a much better place in the
Public Relations’ report than it did at the meeting of the W'oman’s Auxiliary to the
Aunerican Medical Association held in New York last June.

Of course, Hygeia will have as important a place in our program as ever. Perhaps
with the help of all of you, we will be able to increase our subscriptions materially.

And now, having mentioned a few of the things which are uppermost in my mind, let
me introduce you to the new officers and committee chairmen. We are all ready to serve
each and every one of you in any way which we can, so please write us if there is anything
which we can do to help you. 'The list follows :

President-Elect

Vice President

Secretary

Treasurer

Past President

Honorary President

Archives

Bulletin Circulation Manager

Exhibits

Finance

Historian

Hygeia

Legislation

Organization

Parliamentarian

Press

Program

Public Relations

Revisions

Officers

Mrs. William J. Butler, 327 Briarwood Ave., Grand Rapids

Mrs. O. D. Stryker, Fremont

Mrs. Audrey O. Brown, 19575 Renfrew Road, Detroit

Mrs. H. L. French, 1620 W. Main St., Lansing

Mrs. L. G. Christian, 400 Everett St., Lansing

Mrs. Guy L. Kiefer, 148 E. Grand River Ave., Lansing

Committee Chairmen

Mrs. Paul R. Urmston, 1862 McKinley Ave., Bay City

Mrs. Palmer Sutton, 25575 Vork, Royal Oak

Mrs. Galen B. Ohmart, 374 Lodge Drive Detroit

Mrs. Elmer L. Whitney, 18224 Wildemere Ave., Detroit

Mrs. J. Earl McIntyre, 600 S. Grand Ave., Lansing

Mrs. A. Y. Wenger, 132 Grand Ave., Grand Rapids

Mrs. L. G. Christian, 400 Everett St., Lansing

Mrs. John J. Walch, 709 Fifth Ave. S., Escanaba

Mrs. Ledru O. Geib, 1411 Berkshire Rd., Brosse Pointe

Mrs. R. H. Alter, 801 S. West Ave., Jackson

Mrs. Lloyd C. Harvie, 417 Ardussi Rd., Saginaw

Mrs. G. L. Willoughby, 5013 N. Saginaw St., Flint

Mrs. O. D. Stryker, Fremont

Don’t forget that I’m counting on all of you to help make this a successful year for the
W’oman’s Auxiliary to the Michigan State Medical Society !

(AIrs. Roger V.) Helen R. Y'alker, President

Woman’s Auxiliary, Alichigan State ]^Iedical Society.

62

Jour. M.S.M.S.

WOMAN’S AUXILIARY

Bay County

The Woman’s Auxiliary to the Bay County Medi-
cal Society held its first fall meeting on November 13
at the Elks Club, with twenty-two members present for
dinner.

Mrs. W. R. Ballard, president, presided and gave her
report as delegate to the state convention held in
Detroit.

A letter was read stating that the Auxiliary has been
accepted as a member of the Bay County Council of
Social Agencies. Mrs. Ballard will attend a meeting
of this Council November 28.

The Auxiliary is urging that subscriptions be taken to
the Medical Auxiliary Bulletin. Mrs. F. T. Andrews
read a report from the American Medical Association.

The members were asked to assist the local Red
Cross by helping make surgical dressings.

Mrs. R. E. Scrafford, Chairman of rummage sale,
asked that everyone who is willing give two dollars to
our treasurer to take the place of the rummage sale
that had been scheduled for this fall.

The group decided to have the public meeting in
January this year instead of February.

Mrs. Ballard appointed Mrs. F. T. Andrews, Mrs. R.
C. Perkins and Mrs. P. R. Urmston on the member-
ship committee.

Calhoun County

The Calhoun County Medical Auxiliary held its sec-
ond meeting of the year at the home of Mrs. M. R.
Kinde on the evening of November 12.

There were thirty members present and one guest.
Miss Katherine Sleath of London, England.

A donation of $100.00 was given to the Crippled Chil-
dren’s Committee.

It was suggested that the Auxiliary again supply an
adequate Christmas for a needy family. This motion
was approved, and Mrs. Kenneth Lowe appointed a
committee chairman to take charge of the work.

Following the business session the ladies again sewed
for the Red Cross.

Jackson County

The regular monthly meeting of the Jackson County
Medical Auxiliary was held at the Jackson Country
Club, Nov. 19, 1940, and was a combined meeting with
the Dental Auxiliary.

After dinner, the meeting was opened by the presi-
dent, Mrs. G. R. Bullen who introduced Mrs. W. A.
Wickham, chairman of the project committee. Mrs.
Wickham outlined for us the new project this year,
which is to be a personal project to help children whose
normal life is handicapped through lack of glasses,
crutches, etc. The committee is also having a Christ-
mas wrapping party to wrap toys at the home of Mrs.
]^IcGarvey.

The president then introduced Mrs. Harold Greene,
president of the Dental Auxiliary, who thanked the
^ledical Auxiliary for the enjoyable meetings they have
had with us, and expressed the hope they would con-
tinue.

Mrs. Chalmers Johnson then introduced Mrs. Luther
Pahl, violinist and Mrs. Don Lyons, who accompanied
her. They gave us several lovelv numbers and the
meeting was turned over to Mrs. Morris Wertenberger,
the program chairman.

A play entitled “Everybody’s Doing It” was given by
a group from the Medical Auxiliary and was thoroughly
enjoyed by everyone.

Last but not least was our good friend Mrs. Cam-
burn with her movies of Nova Scotia which she took
this Slimmer. They were beautiful and her interest-
ing account of the trip completed a perfect evening.

Kalamazoo County

The November meeting of the Auxiliary to the Kala-
mazoo Academy of Medicine met at the home of Mrs.
Homer Stryker. Thirty members enjoyed a cooperative

dinner. [Mrs. Kenneth Crawford, president, conducted
the business meeting at which time plans and activities
for the year were discussed. The various chairmen
were called upon to give reports. The remainder of
the evening was spent informally.

Kent County

The November meeting of the Woman’s Auxiliary
to the Kent County Medical Society was held in the
Auditorium of the new Public Museum, where the
members of iMrs. M. W. Shellman’s Philanthropic
Committee served luncheon.

Mrs. Guy DeBoer presided at the business meeting
which was followed by Mrs. Clifford B. V\'ightman’s
vivid review of “Trelawny” by Alargaret Armstrong.

\\ e are looking forward to the December meeting
when Dr. V. AI. IMoore will talk to us on “State
Controlled iMedicine.”

Van Buren County

Ten members of the Van Buren Auxiliary enjoyed a
delicious turkey dinner wdth the doctors of the Van
Buren County iMedical society at the Village Hall of
Decatur on Tuesday evening, November 12.

Rules of the essay contest wEich the Auxiliary is
sponsoring were discussed and agreed upon as follows :

General Subject — “Suggestions for improving the
health of young people in Van Buren County.” (Or any
topic found in Hygeia magazine.) Prize.s — First prize
to be $5.00. Five honorable mentions of $1.00 each.
English teachers in each town of the county are asked
to submit two essays from their 10th, 11th, and 12th
grade classes. Essays are to be numbered only. The
name of the student and his town to be enclosed in
an envelope with corresponding number.

Deadline — Essays are to be sent to Mrs. Terwilliger
of South Haven by January 31. Letters announcing
the Hygeia essay contest were sent to English teachers
of the county immediately after this meeting.

The contest has a twofold purpose : first, to popu-
larize Hygeia magazine with high school pupils, and
second, to make libraries and parents Hygeia-minded.

Wayne County

The Woman’s Auxiliary to the W’ayne County Medi-
cal Society held its regular monthly meeting at the
Society’s headquarters on Friday, November 8, 1940.

Following the business session, the members were
addressed bv Mr. J. D. Laux, Executive Director of
Michigan ^Medical Service. Mr. Laux discussed the
objectives of the organization and reported on the
progress made during the first year of its existence.

Mr. Laux stated that a definite trend toward the
socialization of medicine is evidenced by the various
medical surveys which have been made, and by the
numerous efforts at legislation. Since the movement
toward the socialization of medicine will undoubtedly
continue, tbe medical profession must take a very
energetic part in the supervision and direction of ac-
tivities which deal with medical practice. The possi-
bility of increasing incomes so that families with limited
means could meet the costs of a good standard of
living, including adequate medical care seems remote.
Therefore most efforts at a remedy have centered
around a group pre-payment arrangement for the pur-
chase of medical care.

In conclusion, i\Ir. Laux emphasized the advisability
of the members of the Woman’s Auxiliary taking an
active interest in furthering the education of the public
in matters relative to payment for medical service.
Each member should become thoroughly familiar with
^Michigan iMedical Service, as this is the program of
vital importance to doctors and to the public in
Michigan.

Follow ing jMr. Laux’s address, tea was served by the
Social Committee in honor of twenty new members.
Mrs. Howard P. Doub,, Mrs. Richard C. Connelly,
Mrs. Ira G. Downer, and jMrs. Frank A. Weiser were
hostesses.

J.A,XU.\RY, 1941

63

-K

MICHIGAN’S DEPARTMENT OF HEALTH

HENRY A. MOYER, M.D., Commissioner, Lansing, Michigan

-K

1940 STATE'S SAFEST YEAR FOR BABIES?

There is an excellent chance that a new low record
in infant deaths will be established for 1940. For the
first nine months there were 40.64 deaths of babies
under one year for each 1,000 births. The rate for
the same period in 1939 was 41.% deaths per 1,000
births.

If the favorable trend continues, it is likely that the
rate for the year will be below the 41.8 mark of 1939,
which established a record.

In pointing out the possibility of making 1940 the
safest year for new babies that the state has known.
Dr. Lillian R. Smith, director of the Bureau of Ma-
ternal and Child Health, urged each prospective mother
who has not already done so to place herself im-
mediately under the care of a physician. She cautioned
adults to keep their own colds and those of children
away from babies, and said that every new baby and
every infant under a year should have the care of a
family doctor.

MEASI^S INCREASE

Michigan will have a bigger measles epidemic this
winter than the 1935 and 1938 outbreaks, if a sharp rise
in cases this year is an indication.

“The rise in cases is early, and the number is much
larger than reported prior to the last two epidemic
years,” said Dr. H. Allen Moyer, commissioner. “It
would not be surprising to see the total of cases go
higher than 80,000 which was the total in each of the
previous two epidemics. The cases reported so far
this year are 16,000 as compared with 6,500 in 1934
and 6,000 in 1937.”

Dr. Moyer has asked parents to isolate children who
appear to be coming down with a cold, and suggests
that especially in localities where measles is prevalent
the family physician should be called. The symptoms
of a common cold are identical with those of
measles the first day or two. While measles is
communicable before the fever, running nose and
cough symptoms appear, isolation will help protect
babies and young children, for whom measles may be
dangerous. Most measles deaths occur in children
under five years of age.

September, October and November reports of measles
in certain counties have been as follows : Calhoun 16,
61, 286; Kalamazoo 3, 69, 166; Montcalm 9, 59 and 89;
Washtenaw 5, 25, 31. Detroit cases were 96 in Sep-
tember, 334 in October and for the first three weeks of
November, 590. Kent county and Grand Rapids report-
ed less than a dozen cases in November. The total for
the month is approximately 1,600 cases.

DECLINE OF CONTAGION

Only four out of 12 communicable diseases sum-
marized by the Department of Health have been re-
ported more times in the first ten months of this year
than they were in 1939. The four are measles, which

is on the way to a third-year epidemic, whooping cough,
infantile paralysis and gonorrhea.

Ten-month reports showing increases follow with the
1940 total first and the 1939 total second; measles 14,851
and 9,631 ; whooping cough 8,986 and 7,905 ; polio-
myelitis 1,140 and 881 ; gonorrhea 6,370 and 5,618.
Reports showing declines were ; lobar pneumonia
2,303 and 3,146 ; tuberculosis 5,083 and 5,315 ; typhoid
fever 107 and 152; diphtheria 178 and 375; scarlet
fever 8,923 and 10,465 ; smallpox 29 and 167 ; meningitis
35 and 48; syphilis 8,945 and 10,653.

MORE BIRTHS

Provisional figures from the Bureau of Records
and Statistics show that births have increased in the
first nine months of the year, as compared with the
January-September period in 1939. If the increase is
maintained, the gain will be 3,500 for the year.

Births reported from January through September
this year were 73,036, compared with 70,351 a year ago,
a gain of 2,685. The rate per 1,000 population is 18.57
for 1940 and 18.02 for 1939 for these months.

Deaths were down slightly from last year in the
first nine months. The figures were 38,791 for 1940
and 39,290 for 1939. The rates were 9.86 deaths per
1,000 population in 1940 and 10.07 for the first nine
months in 1939.

FIREARMS ACCIDENTS

In filling out death certificates for firearms fa-
talities, a number of physicians have added details
which are of special interest. Among 12 firearms
fatalities in October, one certificate carried the notation
that the hunter (a boy of 18) was killed when he used
his shotgun to club a wounded pheasant. A man of
35 was killed when cleaning his gun, a man of 39 died
in an accidental discharge of his gun, and a man of 61
was killed when he climbed a fence with a gun. A
child of two was killed at home, playing with a gun
of some description.

SHIAWASSEE SIXTY-THIRD

Shiawassee County will be the sixty-third county in
the state to have a full time health department when
its unit begins operation January 1. The Shiawassee
County Medical Society had expressed its support for
the health unit months ago, but approval of the board
of supervisors and provision for finances were made
only recently.

SIXTY-SEVEN POLIO CASES IN NOVEMBER

Three days in the last week of November were the
first since August 2 that no infantile paralysis cases
were reported to the Department. The total for No-
vember was 67, which like the October total of 287
was a new record for the month. The previous No-
vember high was 45 cases in the former record year
of 1931. The total cases of polio reported in 1931 was
1,137. The 11-month total for 1940 is 1,209.

64

Jour. M.S.M.S.

-K COUNTY AND PERSONAL ACTIVITIES -X

i\f j-fff f f ff ff rrf rf rr f rrf rr-f rffr rrr’f'ff f

Th-e Wayne County Medical Society “feather” party
was a huge success. The largest crowd in the Society’s
history, 1,103, jammed the Alasonic Temple for the an-
nual pre-turkey festival on November 19.

:fc 5fc

Frank Power, M.D., M.S.iM.S. Field Representative in
Cancer, addressed a public meeting sponsored by the
Woman’s Auxiliary to the Baj* County iMedical Society,
in Bay City on January 8.

^ ^ ^

Harold A. Miller, M.D., Lansing, represented the
Michigan State Medical Society at the meeting of the
Maternal and Child Health Advisory Committee of the
Michigan Department of Health in Lansing on Decem-
ber 13.

^ 3fc ^

Harold A. Miller, M.D., Lansing, Frank Van Schoick,
M.D., Jackson, and Frederick B. iMiner, Al.D., Flint,
represented the Michigan State Aledical Society at the
meeting of the Child W'elfare Committee of the Michi-
gan Welfare League in Lansing on December 16.

^ ^

Acknowledgement

The color plates facing page 840 in The Journal for
November, 1940, are copyrighted by The American
Tournal of Roentgenology and Radium Therapy, and
nade available to The Journal through the courtesy
Df the American Roentgen Ray Society, Inc.

:(C * ^

The 1941 Convention of the Michigan State Medical
Society will be held in Grand Rapids on September 16,
17, 18, 19, 1941, at the Hotel Pantlind-Civic Auditorium,
the House of Delegates meeting on Tuesday, Septem-
ber 16. The 5th Annual Golf Tournament will be held
at the Kent Country Club on Monday, September 15.

^ ^

The West Side Medical Society of Detroit held its
Eighth Annual Cancer Clinic at Eloise on Decem-
ber 4. The Clinic was conducted by S. E. Gould.

M. D. Speakers included Drs. J. E. Croushore, E. R.
Donoghue, C. A. Doty, T. K. Gruber, J. AI. Grace,

N. K. H’Amada, C. K. Hasley, A. Z. Howard, R. H.
Lyons, H. J. Kullman, W. J. Seymour, W. L. Sherman
and D. C. Somers.

* * ^

“The Surgical Treatment of Hypertension” by Alax
!M. Peet, M.D., Ward W. Woods, M.D. of Ann Arbor
and Spencer Braden, M.D., of Cleveland, appeared in
the Journal of the American Medical Association, issue
of November 30, 1940. In the issue of December 7,
19-10, the following articles appeared : “Acute Ascend-

ing Paralysis” by Russell N. Dejong, M.D., Ann Arbor ;
“Use of Cellophane Cylinders for Desiccating Blood
Plasma” by F. W. Hartman, M.D., with the assistance
of F. W. Hartman, Jr., Detroit.

^ ^ ^

The Third Annual Congress on Industrial Health,
sponsored by The Council on Industrial Health of the
A.M.A., is scheduled for the Palmer House, Chicago,
January 13 and 14, 1941. The very full program in-
cludes discussions on many phases of industrial practice,
including the Physician in Industry and National De-
fense by Irvin Abell, M.D., Louisville ; a symposium on
Hand Injuries, on Availability of Trained Industrial
Health Personnel ; on Acute Respiratory Disease in In-
dustry; and on Industrial Ophthalmology. All physi-
cians interested in industrial practice are invited. No
registration fee. Write The Council on Industrial
Health, American Medical Association, 535 North Dear-
born Street, Chicago, for copy of the program.

Jan-u.-^rv, 1941

Robert B. Harkness, M.D., Hastings, former president
of the Council of the Michigan Department of Health,
has been appointed assistant field director of the \\ .
K. Kellogg Foundation, a newly created position. Doc-
tor Harkness is on leave for study and will begin his
new work in May, working with M. R. Kinde, M.D.,
field director in the seven counties where the Founda-
tion cooperates in health units. J. K. Altland, M.D.,
who resigned as director of the Grand Traverse County
Health Department, succeeds Doctor Harkness in Barry
County.

5jc :}: jj?

Pan American relationships took another step forward
in the field of medicine when the Pan American Con-
gress of Ophthalmology was organized on a permanent
basis at the meeting of the first congress in Cleveland,
October 11-12, 1940, under the auspices of the Ameri-
can Academy of Ophthalmology and Otolaryngology.
Harrj' S. Gradle, M.D., Chicago, was elected president
of the congress. Conrad Berens, M.D., New York and
Moacyr E. Alvaro, Sao Paulo, Brazil, who served with
Doctor Gradle as members of the Committee that or-
ganized the initial meeting, were elected executive sec-
retaries. Montevideo was tentatively selected as the
place of the next meeting, to be held in 1943.

5^ ^ ^

The National Grange at its annual convention in
Syracuse, N. Y., on November 19, 1940, reaffirmed its
stand against federal or politically-controlled medicine.
At the same time the National Grange leaders voiced
their approval of voluntary group medical care plans,
such as Michigan Medical Service which has been in
operation in Michigan for the past nine months. Mem-
bers of the Grange want to be certain they have the
privilege of calling the physician of their choice rather
than a doctor sent by some political bureau. Profes-
sionally controlled voluntary group medical care plans
guarantee free choice of physician which is the inalien-
able right of the American people.

^ ^ ^

The Battle Creek Medical Conference, sponsored by
the Calhoun County Medical Society and the Battle
Creek Sanitarium, was held at the Sanitarium on De-
cember 3. The outstanding array of speakers on the
program included J. Roscoe Miller, M.D., Chicago ;
Cleveland J. \Miite, AI.D., Chicago ; David E. Markson,
M.D., Chicago; ]\I. A. Mortensen, M.D., Battle Creek;
Michael L. Mason, ]\I.D., Chicago ; Harold J. Kullman,
^I.D., Detroit; James T. Case, M.D., Chicago; Arthur
E. Mahle, ]\I.ID., Chicago ; Harry Towsley, M.D., Ann
Arbor ; James K. Stack, M.D., Chicago ; and Stephen
\\'. Ranson, Jr., M.D., Chicago; B. A. Watson, M.D.,
Battle Creek ; and C. W. Brainard, M.D., Battle Creek.
The Conference ended in the evening with a banquet
followed with a talk by Morris Fishbein, M.D., Editor
of the Journal of the American Medical Association.

^ ^ ^

The Mississippi Valley Medical Society offers annual-
ly a cash prize of $100, a gold medal, and a certificate
of award for the best unpublished essay on any subject
of general medical interest (including medical eco-
nomics) and practical value to the general practitioner
of medicine. Contestants must be members of the
American ^Medical Association who are residents of
the United States. The winner will be invited to
present his contribution before the next annual meet-
ing of the ^lississippi Valley Medical Society at Cedar
Rapids, Iowa, October 1, 2, 3, 1941. Contributions shall
not exceed 5,000 words, be typewritten in English in
manuscript form, submitted in five copies and must be

65

COUNTY AND PERSONAL ACTIVITIES

evidence continues to support the thera-
peutic effectiveness of Sulfathiazole in
the treatment of Pneumococcal and
Staphylococcal infections.

SULFATHIAZOLE (thiazole anal-
ogue of sulfapyridine) has been clinically
demonstrated to be less toxic than either
sulfanilamide or sulfapyridine. More-
over there are a number of observations
which indicate that the sulfathiazole
group definitely lessens the incidence
and severity of vomiting. Other advan-
tages are more uniform and rapid absorp-
tion, less conjugation after absorption,
and greater effectiveness against the
Staphylococcus.

SULFATHIAZOLE, “Ciba” (2-sul-

fanilyl-aminothiazole) is available in 0.5
gram tablets, in bottles of 50, 100, 500 and
1000. Also available are 5 gm. bottles of
Sulfathiazole crystals for making reagent
solutions for estimation of sulfathiazole
content of the blood.

CIBA PHARMACEUTICAL PRODUCTS, live.

SUMMIT NEW JERSEY

received not later than May 1, 1941. Further details
may be secured from Harold Swanberg, M.D., 209
WCU Building, Quincy, Illinois.

^ 5JC

The Radio Committee of the M.S.M.S. advises that
the following Health Talks were broadcast over radio
station CKLW :

Saturday, November 16, 1940 — 1 ;15 p.m. “The Com-
mon Cold” by Arthur E. Hammond, M.D., Detroit.

Saturday, November 23, 1940 — 1:15 p.m. “Influenza”
by Thomas Horan, M.D., Detroit.

Saturday, November 30, 1940 — 1 :15 p.m. “Pneumonia”
by Thomas G. McKean, !\I.D., Detroit.

Saturday, December 7, 1940 — 1 :15 p.m. “Osteomyeli-
tis” by Eugene A. Osius, M.D., Detroit.

Saturday, December 14, 1940 — 1 :15 p.m. “The Value
of X-ray Examinations in Accident and Emergency
Cases” by E. R. Witwer, Detroit.

Saturday, December 21, 1940 — 1:15 p. m. “Colitis” by
Harold Kullman, M.D., Detroit.

Saturday, December 28, 1940 — 1 :15 p.m. “\\ intertime
Accidents” by Luther R. Leader, M.D., Detroit.

Saturday, January 4, 1941 — 1 :15 p.m. — “Sinus Dis-
ease” by Wm. S. Gonne, !M.D., Detroit.

The Joint Committee on Health Education has avail-
able through the Extension Division of the University
of Alichigan the following educational health films :
“Preventing Blindness and Saving Sight” (silent — 2
reels) ; “Behind the Shadows” (Tuberculosis Associa-
tion, sound — 1 reel) ; “Foods and Nutrition” (sound —
1 reel) ; “With These Weapons” (^Xmerican Social Hy-
giene Ass’n — sound — 1 reel) ; “Care of the Premature
Child”; “Louis Pasteur” (sound — 2 reels); “That
Mothers Might Live” (sound — 1 reel) ; “They Live
Again” (sound — 1 reel) ; “Tracking the Sleeping Death”
(sound — 1 reel) ; “Circulatory Control” (silent) ; “The
Feet” (silent) ; “Heart Disease” (sound — March of
Time) ; “Heredity” (sound) ; “Life of the Healthy
Child” (silent) ; “Milk and Health” (sound — March of
Time) ; “Moving X-Rays” (sound) ; “Nurses in the
Making” (silent — 2 reels) ; “The Alimentary Tract”
(sound) ; “The Blood” (silent — reel) ; and “Cancer,
Its Cure and Prevention” (sound— March of Time).

During the year ending July 1, 1940, Tlie Joint Com-
mittee on Health Education has sponsored 148 lectures
on Cancer, Syphilis and Sex Education, Dental Hj--
giene, Alental Hygiene, Child Problems, Skin, Tuber-
culosis, Child Welfare, General Health, Crippled Chil-
dren, iMedical Care, Nursing and Maternal Hygiene.
The Committee has sponsored twent\--four talks on
similar subjects over twelve radio stations in Michigan.
Health bulletins have been issued by the Committee on
the subjects of “Problem Solving Approach in Health
Teaching”; “Health Goals for the School Child” and
“Experiences in Healthful Living as Developed by
Teachers” and pamphlets on cancer. With the assist-
ance of the iMichigan Department of Health over 20,000
of these bulletins have been distributed.

jjc

COUNCIL AND COMMITTEE MEETINGS

1. Wednesda}% December 18, 1940 — 1 :00 p.m. — Child
Welfare Committee, WCiHS Bldg., Detroit.

2. Wednesday, December 19, 1940 — 6 :00 p.m. — Execu-
tive Committee of The Council, Hotel Statler, Detroit.

3. Friday, January 10, 1941 — 6:30 p.m. — Finance Com-
mittee of The Council, Detroit.

4. Frida}', January 10, 1941 — 6:30 p.m. — Publication
Committee of The Council, Detroit.

5. Friday, January 10, 1941 — 6:30 p.m. — County So-
cieties Committee of The Council, Detroit.

6. Saturday and Sunday. January 11 and 12, 1941 —
Midwinter iMeeting of The Council, Detroit.

Jour. M.S.M.S.

66

Say you sazv it in the Journal of the Michigan State Medical Society

COUNTY AND PERSONAL ACTIVITIES

DISTRICT MEETINGS

The Second District meeting will be held on Thurs-
day, January 16, 1941, Hayes Hotel, Jackson, with Coun-
silor Philip A. Riley, M.D., presiding. President-elect
Henry R. Carstens, M.D., Detroit, will speak on “Michi-
gan Aledical Service” ; Secretary L. Fernald Foster,
M.D., Bay City, will discuss “Organizational Activities”;
and President P. R. Urmston, M.D., Bay City, will out-
line the latest developments in “Medical Preparedness.”
Other officers and councilors from neighboring districts
will be guests of honor.

The Eighth District meeting will be held at Saginaw,
January 23, 1941, with Councilor W. E. Barstow, M.D.,
St. Louis, presiding. President-elect Henry R. Carstens,
M.D., Detroit, will discuss “Michigan Medical Service” ;
“Organizational Activities, Including Legislation” will
be presented by Secretary L. Fernald Foster, M.D.,
Bay City ; Executive Secretary Bill Burns will speak
on “Medical Welfare” ; and “Medical Preparedness”
will be outlined by P. R. Urmston, M.D., president.
Bay City.

The Fifteenth District meeting was held on Wednes-
day, January 8, 1941, at Rotunda Inn, Pine Lake, Coun-
cilor Otto O. Beck, M.D., Birmingham, presiding. Presi-
dent-elect Henry R. Carstens, M.D., Detroit, spoke on
“Michigan Medical Service” ; Secretary L. Fernald
Foster, M.D., Bay City, outlined “Organizational Ac-
tivities, Including Legislation and Medical Welfare” ;
and President P. R. Urmston, M.D., Bay City, spoke
on “Medical Preparedness.”

COUNTY MEDICAL SOCIETY MEETINGS

Bay — Wednesday, November 27 — Wenonah Hotel,
Bay City — Speaker : Clair Folsome, M.D.

Ann Arbor — Wednesday, December 18 — Bay City
Country Club — Annual Meeting.

Calhoun — Tuesday, December 3 — Battle Creek Sani-
tarium— Annual Meeting. Speaker : Morris Fishbein,

Al.D., Chicago.

Chippewa-Mackinac — Friday, December 13 — Annual
fleeting.

Dickinson-Iron — Thursday, December 5 — Annual
Meeting.

Genesee — Wednesday, November 27 — Flint — Annual
Meeting.

Gratiot-I sahella-Clare — Thursday, December 19, Alma
Annual Christmas Party.

Hillsdale — Thursday, November 28 — Hillsdale —
Speaker: John Sheldon, M.D., Ann Arbor.

Ingham — Tuesday, December 17, Lansing — Annual
Meeting.

lonia-Montcalm — Tuesday, December 10, Greenville —
Speaker : Reed O. Dingman, M.D., D.D.S., Ann Arbor.

lackson — Tuesday, November 19, Jackson — Speaker:
Harther L. Keim, AI.D., Detroit. Tuesday, December 17,
Jackson — Annual Christmas Party.

Kalamazoo — Tuesday, December 17, Kalamazoo —
Annual fleeting. Speaker : Hon. George E. Bushnell,

Chief Justice, ^klichigan Supreme Court.

Kent — Tuesday, December 10, Grand Rapids — Annual
^Meeting.

Lenaivcc — Tuesday, November 19, Adrian — Speaker :
John Barnwell, iH.D., Ann Arbor.

Muskegon — Friday, December 13, Muskegon — Annual
Meeting.

Oakland — Wednesday, December 4, Pine Lake — An-
nual iMeeting.

Ontonagon — Wednesday, December 4, Ontonagon —
Annual Meeting.

St. Clair — Tuesday, November 26, Port Huron —
Speaker: Dr. Mitchell, Detroit. Tuesday, December

10, Port Huron — Speaker : Clifford D. Benson, Detroit.
Tuesday, January 7, St. Clair Inn, St. Clair — Annual
Meeting.

Washtenaw — Tuesday, December 10, Ann Arbor —
Speaker : Charles F. ^IcKhann, !M.D., Ann Arbor.

Janu.arv, 1941

Main Entrance

SAWYER SAMTDRIUM

White Daks Farm

Marion, Ohio

For the treatment of
Nervous and Mental Diseases
and Associated Conditions

Licensed for

The Treatment of Mental Diseases
by the Department of Public Welfare
Division of Mental Diseases
of the State of Ohio

Accredited by

The American College of Surgeons
Member of

The American Hospital Association
and

The Ohio Hospital Association

Housebook giving details, pictures,
and rates will be sent upon request.
Telephone 2140. Address,

SAWYER SAMTDRIUM

White Daks Farm

Marion, Ohio

Say you sazv it in the Journal of the Michigan State Medical Society

67

COUNTY AND PERSONAL ACTIVITIES

\ndicated
for ^Aemorable
^Aoments

It’s professional to let your taste
prescribe the Scotch of its own
choosing . . . fine-flavoured Johnnie
Walker. For there’s no finer whisky
than Scotch and Johnnie Walker
is Scotch at its smooth, mellow best.

IT'S SENSIBLE TO STICK WITH

Johnnie

\yALKER

BLENDED SCOTCH WHISKY

CANADA DRY GINGER ALE, INC., NEW YORK, N. Y.
SOLE IMPORTER

IVayne — November 4 — 1st and 16th District Meeting.
November 11 — Medical Meeting. Speaker: Joseph T.

W'earn, ]\I.D., Cleveland. November 19 — Feather Party.
November 25 — Symposium on Peptic Uulcer. December
2 — “Medicine in the Defense Program” by Irvin Abell,
AI.D., Louisville, Ky'. December 9 — Speaker ; Soma
Weiss, M.D., Boston. December 16 — General Practice
Meeting — Speakers : Harry Miller, M.D., Wm. Car-

penter, M.D., Wm. H. Good, M.D., and R. T. Crowley,
M.D. January 6 — Speaker: Howard T. Karsner, M.D.,
Cleveland.

* * *

NEW COUNTY MEDICAL SOCIETY OmCERS
Allegan

President — R. J. Walker, !M.D., Saugatuck
Vice President — Bert Van Der Kolk, M.D., Hopkins
Secretary — E. B. Johnson, M.D., Allegan
Treasurer — H. M. Benning, M.D., Allegan
Delegate — C. A. Dickinson, M.D., Wayland
Alternate — W. C. Medill, !M.D., Plainwell
Bay-Arenac-Iosco

President — R. N. Sherman, M.D., Bay City'
President-Elect — Fred Drummond, M. D., Kawkawlin
Secretary-Treasurer — L. Fernald Foster, M.D., Bay City
Medico-Legal Advisor — E. A. Wittwer, M.D., Bay City
Delegates — C. L. Hess, iM.D., Bay City ; Fred Drum-
mond, M.D., Kawkawlin

Alternates — R. H. Criswell, M.D., Bay City; I. N.
Asline, iM.D., Essexville

Calhoun

President — Harry' F. Becker, M.D., Battle Creek.
President-Elect — John E. Cooper, M.D., Battle Creek.
Vice President — Benjamin G. Holtom, M.D., Battle
Creek.

Secretary-Treasurer — Wilfrid Haughey, M.D., Battle
Creek.

Delegates — Harvey Hansen, M.D., Battle Creek; A.

T. Hafford, AI.D., Albion.

Alternate Delegates — Geo. \\ . Slagle, M.D., Battle
Creek; A. A. Humphrey, M.D., Battle Creek.

Chippewa-Mackinac

President — B. T. ^Montgomery, M.D., Sault Ste. Marie.
Vice President — Clayton Willison, !M.D., Sault Ste.
Marie.

Secretary-Treasurer — L. J. Hakala, M.D., Sault Ste.
Alarie.

Delegate — L. iM. iMcBryde, M.D., Sault Ste. Marie.
Alternate — \\'. F. iMertaugh, M.D., Sault Ste. Marie.

Clinton

President — Dean \\ . Hart, }\LD., St. Johns.

Vice President — S. R. Russell, AI.D., St. Johns.
Secretary-Treasurer — T. Y. Ho, M.D., St. Johns.
Delegate — G. H. Frace, M.D., St. Johns.

Alternate Delegate — W. B. iMcW'illiams, M.D., Maple
Rapids.

Dickinson-Iron

President — Harry H. Haight, M.D., Crystal Falls.
President-Elect — R. E. White, M.D., Stambaugh.
Secretary-Treasurer — E. B. Andersen, M.D., Iron
Mountain.

Delegate — W. H. Ale.xander, M.D., Iron Mountain.
Alternate Delegate — E. B. Andersen, !M,D., Iron
Mountain.

Genesee

President — Clifford V\ . Colwell, AI.D., Flint.
President-Elect — Donald R. W right, AI.D., Flint.
Secretary — John S. Wyman, M.D., Flint.

Treasurer — Donald L. Bishop, AI.D., Flint.
Medico-Legal Officer — Herbert Randall, M.D., Flint.
Delegates : George J. Curry, AI.D., Donald R. Brasie,
M.D., Frank E. Reeder, ]M.D. and Henry Cook,
M.D., all of Flint.

Alternates — Robert Scott, M.D., A. Dale Kirk, M.D.,

T. S. Conover, Al.D., and Frank Johnson, M.D.,
all of Flint.

68

Say you saw it in the Journal of the Michigan State Medical Society

Jour. M.S.M.S.

COUNTY AND PERSONAL ACTIVITIES

Grand Traverse-Leelanau-Benzie

President — James W. Gauntlett, M.D., Traverse City
Vice President — Dwight Goodrich, M.D., Traverse City
Secretary-Treasurer — I. H. Zielke, M.D., Traverse City
Medical Legal Advisor — Fred G. Swartz, M.D., Trav-
erse City

Ingham

President — Harold W. W iley, M.D., Lansing.
President-Elect — O. M. Randall, M.D., Lansing.
Secretary — R. J. Himmelberger, M.D., Lansing.
Treasurer — Charles R. Doyle, M.D., Lansing.
Delegates — C. F. DeVries, M.D., Lansing; T. I.
Bauer, M.D., Lansing; L. G. Christian, M.D.,
Lansing.

Alternates — Robert S. Breakey, M.D., Lansing ; R. L.
Finch, M.D., Lansing; C. S. Davenport, M.D.,
Lansing.

lonia-Montcalm

President — L. L. Marston, M.D., Lakeview.
President-Elect — Joseph J. Johns, M.D., Ionia.
Secretary-Treasurer — John J. McCann, M.D., Ionia.
Delegate — W. L. Bird, M.D., Greenville.

Alternate — C. T. Pankhurst, M.D., Ionia.

Member of the Council — F. M. Marsh, M.D., Ionia.
Member of Ethics Committee — H. M. Maynard, M.D.,
Ionia.

Lenawee

President — Bernard Patmos, M.D., Adrian.
Vice-President — A. O. Abraham, M.D., Hudson.
Secretary-Treasurer — Esli T. Morden, M.D., Adrian.
Delegate — A. W. Chase, M.D., Adrian.

Alternate — Bernard Patmos, M.D., Adrian.

Manistee

President — E. B. Miller, M.D., Manistee

Vice President — W. Norconk, M.D., Bear Lake

Secretary-Treasurer — C. L. Grant, M.D., Manistee

Medical Society of North Central Counties

President — Stanley A. Stealy, M.D., Grayling
Vice President — L. A. LaPorte, M.D., Gladwin
Secretary-Treasurer — C. G. Clippert, M.D., Grayling

Ontonagon

President — ^J. L. Bender, M.D., Mass.

President-Elect — H. B. Hogue, M.D., Ewen.
Secretary-Treasurer — R. J. Shale, M.D., Ontonagon.
Delegate — W. F. Strong, M.D., Ontonagon.

Alternate — H. B. Hogue, M.D., Ewen.

Ottawa

President — C. E. Long, M.D., Grand Haven
Vice President — J. Ver Duin, M.D., Grand Haven
Secretary-Treasurer — D. C. Bloemendaal, M.D., Zee-
land

Sanilac

President— H. H. Learmont, M.D., Croswell.
Secretary-Treasurer — E. W^ Blanchard, AI.D., Decker-
ville.

Tuscola

President — W. P. Petrie, M.D., Caro.

President-Elect — E. C. Swanson, M.D., Vassar.
Secretary-Treasurer — W^. Dickerson, M.D., Wahja-
mega.

Delegate — T. E. Hoffman, M.D., Vassar.

Alternate — W^ Dickerson, M.D., Wahjamega.

Makes It Convenient and Quick to Test
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Test Sets: “Pollen Pak/' “The
Physician/' “The Group" and “The
Clinic." Treatment Materials {700-
1000 allergens available): Pollens,

The Barry Service is the only spe-
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for physicians' use. Then, your in-
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filled with freshly prepared desen-
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The Barry Allergy Laboratory
is represented by the leading med-
ical distributors throughout the
“Hay Fever Belt."

Foods, Epidermals, Fungi, and
Bacteria. Write for descriptive lit-
erature. The Barry Allergy Lab-
oratory, 220 Bagley, Detroit, Mich.

January, 1941

Say you saw it in the Journal of the Michigan State Medical Society

69

IN MEMORIAM

LABORATORY APPARATUS

Coors Porcelain
Pyrex Glassware
R. & B. Calibrated Ware
Chemical Thermometers
Hydrometers
Sphygmomanometers

J. J. Baker & Co., C. P. Chemicals
Stains and Reagents
Standard Solutions

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Serums Vaccines

Antitoxins Media

Bacterins Pollens

We are completely equipped and solicit
your inquiry for these lines as well as for
Pharmaceuticals, Chemicals and Supplies,
Surgical Instruments and Dressings.

RUPP & mm CO.

319 SUPERIOR ST., TOLEDO, OHIO

jWcmoriam

Herbert W. Hewitt of Detroit, Michigan, was born
October 13, 1875, in Milford, Michigan, and was gradu-
ated from the Detroit College of Medicine in 1903,
after which time he served a two-year internship at
Harper Hospital. This was followed by an assistant-
ship to William F. Metcalf, M.D., for a period of six
years. From 1904-1909 he was Demonstrator of Anat-
omy in the Detroit College of Medicine and Surgery.
He took postgraduate work in pathology at the Uni-
versity of Michigan and was Clinical Professor of
Surgery at the Detroit College of Medicine and Surg-
ery between 1918-1920. In 1923 he became Attending
Surgeon at Grace Hospital, a position he held for
many years until he became Chief of the Surgical
Department. Doctor Hewitt was the author of numer-
ous articles, chiefly on surgery, which appeared in local,
state and national journals. He died October 17, 1940.

Edwin C. Hoff of Detroit, Michigan, was born
April 20, 1875, in Carey, Ohio, and was graduated
from the Cleveland Homeopathic Medical College in
1901. Following graduation, he came to Detroit to
intern in Grace Hospital. Completing his internship,
he established an office on West Fort Street. He
remained in this location but a short time, moving to
101 Broadway. He moved his office to the David Whit-
ney Building when it was erected in 1915. Doctor
Hoff was a member of the State Homeopathic Society
and a Fellow of the American College of Surgeons,
as well as other organizations. He died October 23,
1940.

Arthur E. Leitch of Saginaw, Michigan, was born
near Toronto, Ontario, Canada, in 1872, and was
graduated from the Detroit College of Medicine in
1893. He first located in Ohio and then moved to
Saginaw where he practiced for forty years. Doctor
Leitch was a member of the staff of both St. ^Mary’s
and St. Luke’s Hospitals. During the World War he
served in the Medical Corps. In 1931 he was president
of the Saginaw County Medical Society. Doctor Leitch
died December 9, 1940.

Moses Emmett Morton of Detroit was born in
Lowndes County, Alabama, in 1888 and was graduated
from the University of Michigan in 1918. He located
in Lowndesboro and later came to Detroit and opened
an office in “Black Bottom” where he became the friend
and teacher to many young Negro medical men in the
art of surgery during their resident da3'S. He was on
the staff of Trinit>' Hospital. Doctor Morton died
November 12, 1940.

Herman G. Rosenblum of Flint, Michigan, was
born September 30, 1892, was graduated from the Uni-
versity of Pittsburgh and Toledo Medical College in
1919 and located in Calumet, Michigan. He served with
the United States Air Service overseas for two years
and was wounded twice. Following the war. Doctor
Rosenblum gave up the practice of medicine and was
associated with his father in the clothing business.
Later he studied proctologj- under L. J. Hirschman,
AI.D., of Detroit and returned to the medical pro-
fession, opening his offices in Flint, March, 1934.
Doctor Rosenblum died October 27, 1940.

Bruno J. Sawicki of Detroit. Michigan, was born
in Cleveland, Ohio, May 15, 1889, and was graduated
from Western Reserve College and the Detroit College
of IMedicine in 1917. In the World War he served as
Captain in the U. S. Medical Corps. Doctor Sawicki
had practiced in Detroit for twenty-four years and his
death was the result of injuries sustained in an auto-
mobile accident near Bay City, October 12, 1940.

Chester Ambrose Wilkinson, of Kendall, Michi-
gan, was born in Harveyville, Penns>’lvania, Januar\'
8, 1862, and was graduated from the Jefferson Medical
School at Philadelphia, Pa., in 1888. In 1890 he moved
to Michigan, taking up residence in Kendall where
he had lived for the past half century. Dr. Wilkinson
was on the staff of Bronson Hospital. He died on
October 11, 1940.

Doctor, remember your particular friends, the exhibi-
tors, at your annual convention, when )’ou have need
of equipment, appliances, medical supplies, and service.
Here are ten of the firms which helped make the 1940
Convention such a success ;

S.M.A. Corporation, Chicago

Sharp & Dohme, Philadelphia

Scientific Sugar Company, Columbus, Indiana

Sobering Corporation, Bloomfield, New Jersey

W. B. Saunders Company, Philadelphia

Frank N. Ruslander, Detroit

Randolph Surgical Supply Company, Detroit

Ralston Purina Company, Inc., St. Louis, Missouri

Professional Management, Battle Creek

Philip Morris & Company, New York

70

Tour. M.S.M.S.

THE DOCTOR’S LIBRARY

THE DOCTOR’S LIBRARY

Acknowledgement of all books received will he made in this
column and this will be deemed by us as a full compensation
of those sending them. A selection will he made for review,
as expedient.

THE 1940 YEAR BOOK OF GENERAL MEDICINE. Edi^d
by George F. Dick, M.D.; J. Burns Amberson, Jr., M.D.;
George R. Minot, M.D., S.D., F.R.C.P. (Edinburgh and
London); William B. Castle, M.D., A.M., M.D. (Hon.),
Utracht; William D. Stroud, M.D.; George B. Eusterman,
M.D. Chicago: The Year Book Publishers, Inc., 1940.

Price: $3.00.

Forty years ago the first volume of the Year Book
of General Medicine was published with Frank Billings
as the principal editor. In this fortieth edition there
are 934 pages instead of the original 274. The editors
now include George Dick, George R. Minot and William
D. Stroud. In addition to the usual review of the litera-
ture there are new features ; such as, discussion of
oral immunization against scarlet fever by Dick, Minot’s
and Castle’s color plate on differential diagnosis of
congenital hemolytic jaundice, articles by Stroud on
digitalis, cancer of the stomach by Eusterman, and the
physician and the tuberculosis campaign by Amberson.

HEMORRHOIDS AND THEIR TREATMENT: THE VARI-
COSE SYNDROME OF THE RECITUM. By Kasper Blond,
M.D., Vienna; Formerly First Assistant, Rothchild Hospital,
Vienna; Hon. Consulting Surgeon, Municipal Hospital,
Vienna; etc. Translated by E. Stanley Lee, M.S., F.R.C.S.,
Hon. Assistant Surgeon, Westminster Hospital. A William
Wood Book. Baltimore: The Williams & Wilkins Company,
1940. Price: $4.50.

E. Stanley Lee of W estminster Hospital in London
has worked with the author in preparing a new edition,
in the English language, of the German edition pub-

lished in 1935. Kasper Blond is an ardent proponent
of the injection treatment of certain anal and rectal
disorders and has achieved great success. The color
plates are beautiful. The subject is treated in a very
instructive manner. This monograph should be of value
to any practitioner who does anal injection therapy.

TABER’S CYCLOPEDIC MEDICAL DICTIONARY, Includ-
ing a Digest of Medical Subjects. By Clarence Wilbur
Taber, and Associates. 273 Illustrations. Philadelphia: F.
A. Dayis Company, 1940. Price: Cloth, Thumb-indexed

$3.00; Plain $2.50.

This dictionarji, a volume seven by five inches, con-
tains fifteen hundred pages and almost as many words
as the larger unabridged medical dictionaries. There
are numerous illustrations and a legible type. Numerous
tables, glossaries, etc., are included making it a very
handy and useful desk volume.

THE PRACTICE OF MEDICINE. By Jonathan Campbell
Meakins, M.D., LL.D., Professor of Medicine and Director
of the Department of Medicine, McGill University; Phy-
sician-in-Chief, Royal Victoria Hospital, Montreal; Formerly
Professor of Therapeutics and Clinical Medicine, University
of Edinburgh. Fellow of the Royal Society of Edinburgh;
Fellow of the Royal Society of Canada; Fellow of the
Royal College of Physicians, London; Fellow of the Royal
College of Physicians, Edinburgh; Honorary Fellow of the
Royal College of Physicians, Canada; Fellow of the Ameri-
can College of Physicians. Third Edition. With 562 Illus-
trations including 48 in color. St. Louis: The C. V. Mosby
Company, 1940. Price: $10.00.

This is the third edition of Doctor Meakins’ textbook
on medicine first published in 1936. Noted for its many
illustrations in the first two edtions, there have been
additional cuts and color plates added which should
aid the student and practitioner to a great degree. It
is not a book to be used for quick reference but is
quite readable. The newer discoveries of medicine are
included and the general subject matter is carefully

i

Complete information mailed on request

★ JOHN WYETH & BROTHER, INCORPORATED ★

IPHILADELPHIA, PA.I

Silver Picrate is a definite crystalline
compound of silver and picric acid.
Available in the form of crystals and
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J.\NU.^RY, 1941

Say you saw it in the Journal of the Michigan State Medical Society

71

THE DOCTOR’S LIBRARY

Cook County

Graduate School of Medicine

(In Affiliation with Cook County Hospital)

Incorporated not for profit

ANNOUNCES CONTINUOUS COURSES

SURGERY — Two Weeks Intensive Course in Surgical
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OBSTETRICS — Two Weeks Intensive Course starting
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OTOLARYNGOLOGY — Two Weeks Intensive Course
starting April 7. Informal and Personal Courses every
week.

OPHTHALMOLOGY — Two Weeks Intensive Course
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prepared in a manner easily assimilable. The typography
is excellent and the green tinted paper is a welcome
aid to night reading.

PHYSIOLOGY AND ANATOMY. By Esther M. Greisheimer,
B.S. in Education, M.A., Ph.D., M.D., Professor of Physiol-
ogy, Woman’s Medical College of Pennsylvania Philadelphia;
Formerly Associate Professor of Physiology The University
of Minnesota, Minneapolis. 471 Illustrations of which 52
are in color. Fourth Edition, Revised and Reset. Phila-
delphia, London, Montreal: J. B. Lippincott Company, 1940.
Price: $3.50.

Dr. Esther Greisheimer has written this volume as
a textbook for the student nurse and the physical edu-
cation student and approaches the two subjects in a
correlated manner establishing the inter-relationship be-
tween physiology and anatomy. The pre-medical student
who has read this book will find the later intensive
study of these subjects in medical school much easier to
absorb, and it should also prove of great value to the
practitioner who wishes to refresh his memory on these
subjects.

FRACTURES AND DISLOCATIONS FOR PRACTITIONERS.
By Edwin O. Geckeler, M.D., Fellow of the American Col-
lege of Surgeons, Fellow of the American Academy of
Orthopedic Surgeons, Diplomate of the American Board
of Orthopedic Surgery. Second Edition. A William Wood
Book. Baltimore: The Williams & Wilkins Company, 1940.
Price: $4.00.

The claim of the publisher that here are “Foolproof
Procedures for Practitioners” may be a bit extreme
since there are no foolproof procedures in medicine (or
in any other business or profession) but undoubtedly
following the instructions given in this volume would
considerably reduce the number of poor results in frac-
ture work and the inevitable suits for malpractice. The
extreme practicality of this three hundred page text-
book for practitioners places it in the recommended
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GRAND RAPIDS, MICHIGAN

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Sanitarium Hotel Accommodations

72

Say you sazv it in the Journal of the Michigan State Medical Society

Jour. M.S.M.S.

MISCELLANEOUS

MEDICAL PREPAREDNESS COMMITTEES

Michigan State Medical Society Committee

Burton R. Corbus, Chairman, Grand Rapids ; E. G.
Buesser, Detroit; L. Eernald Eoster, Bay City; H. H.
Riecker, Ann Arbor ; A. B. Smith, Grand Rapids ; and
P. R. Urmston, Bay City.

County Society Committees

Allegan — W. R. Vaughan, Plainwell, Chairman; H. T.
Stuch and J. H. VanNess of Allegan.

Alpena-Alcona-Presque Isle — E. S. Parmenter, Chair-
man, W. E. Nesbitt and J. A. Ramsey, all of Alpena.

Barry — Gordon Eisher, Chairman, and Robert B. Dark-
ness of Hastings; Herbert Wedel, Freeport.

Bay-Arenac-Iosco — Roy C. Perkins, Chairman, J. H.
McEwan and iM. R. Slattery, all of Bay City.

Berrien — Fred Henderson, Niles, Chairman ; Carl
Mitchell, Benton Harbor; C. S. Emory, St. Joseph.

Branch — R. L. Wade, Coldwater, Chairman; J. E.
Bailey, Bronson ; and N. J. Walton, Quincy.

Calhoun — R. C. Winslow, Chairman ; Russell L. Mus-
tard, Harvey Hansen, all of Battle Creek.

Cass — Geo. Loupee, Chairman, and R. I. Clary of Do-
wagiac ; and U. M. Adams, !Marcellus.

Chippewa-Mackinac — Clayton Willison, Chairman; L. J.
Hakala and E. O. Gilfillan, all of Sault Ste. Marie.

Clinton — F. E. Luton, St. John’s, Chairman; W. B.
^IcWilliams, Maple Rapids ; F. D. Richards, DeWitt.

Delta-Schoolcraft — W. A. LeMire, Chairman ; J. J.
Walch, and D. H. Boyce, all of Escanaba.

Dickinson-Iron — D. R. Smith, Iron Mt., Chairman;
R. E. White, Stambaugh ; Harry Haight, Crystal
Falls.

Eaton — C. L. D. McLaughlin, Vermontville, Chairman;
Don V. Hargrave, Eaton Rapids ; E. G. Stanka, Grand
Ledge.

Genesee — Ray S. Morrish, Chairman ; M. S. Chambers
and Wm. W. Stevenson, all of Flint.

Gogebic — D. C. Eisele, Ironwood, Chairman ; C. E.
Stevens, Bessemer; H. A. Tressel, Wakefield.

Grand Traverse-Leelanau-Benzie — h. R. Way, Chair-
man ; H. B. Kyselka and J. H. Altland, all of
Traverse City.

Gratiot-Isabella-Clare — E. S. Oldham, Breckenridge,
Chairman ; F. G. Slattery, Clare ; and R. H. Strange,
Mt. Pleasant.

Hillsdale — B. F. Green, M.D., Hillsdale, Chairman ;
W. H. Allegar, Pittsf ord ; H. C. Miller, Hillsdale.

Houghton-Baraga-Keweenaw — T. P. Wickliffe, Calu-
met, Chairman ; Leonard Aldrich, Hancock ; Maurice
Kadin, Calumet.

Huron — Willet Harrington, Bad Axe, Chairman.

Ingham — John Wellman, Chairman; Milton Shaw, T.

P. Vanderzalm, all of Lansing.
lonia-Montcalm — W. W. Norris, Portland, Chairman ;

M. A. Hoffs, Lake Odessa ; L. S. Dunkin, Greenville.
Jackson — Geo. A. Seybold, Chairman ; Wayne A. Coch-
rane, Corwin S. Clarke, all of Jackson.

Kalamazoo — Mathew Peelen, Richard U. Light and
Hugo Aach, all of Kalamazoo.

Kent — Paul Willits, Chairman ; Leon Sevey and J. B.

Whinery, all of Grand Rapids.

Lapear — Fred Hanna, Chairman, and H. M. Best of
Lapear, and C. D. Chapin, Columbiaville.

January, 1941

Lenawee — A. W. Chass, Chairman ; L. J. Stafford and
E. T. Morden, all of Adrian.

Livingston — ^J. J. Hendron, Fowlerville, Chairman; H. L.
Bigler and S. Gamble, Howell.

Luce — G. F. Swanson, Chairman ; M. A. Siurell and
W. R. Purmort, Jr., all of Newberry.

Macomb — R. W. Ullrich, Mt. Clemens, Chairman ; A. B.
Bower, Armada ; A. M. Rothman, East Detroit.

Manistee — Harlen MacMullen, E. A. Oakes and J. F.
Konopa, all of Manistee.

Marquette-Alger — N. J. McCann, Chairman, and A. W.
Erickson of Ishpeming; H. P. Blake, Marquette.

Mason — R. A. Ostrander, Chairman ; H. B. Hoffman,
and L. J. Goulet, all of Ludington.

Mecosta-Osceola-Lake — James B. Campbell, Big Rap-
ids, Chairman ; J. A. White, Morley ; P. B. Kilmer,
Reed City.

Menominee — F. J. Dewane, Menominee, Chairman ; K.

C. Kerwell, Stephenson; John Towey, Powers.
Midland — ^Joseph Sherk, Chairman; Chas. MacCallum
and Harold H. Gay, all of Midland.

Monroe — J. H. McMillin, Monroe, Chairman ; H. L.

Meek, Dundee ; W. A. Hunter, iMonroe.

Muskegon — E. O. Foss, Chairman ; L. E. Holly and
Roy Herbert Holmes, Muskegon.

Newaygo — T. R. Duer, Grant, Chairman; O. D. StrjLer,
Fremont, and A. C. Tompsett, Hesperia.

Northern Michigan (Antrin, Charlevoix, Cheboygan,
Emmet) — Wesley East, Petoskey, Chairman; Fred
Mayne, Cheboygan; Jerrian VanDellen, Ellsworth.
Oakland — h. A. Farnham, Chairman; Ethan B. Cudnej^
and Chauncey G. Burke, all of Pontiac.

Oceana — J. H. Nicholson, Chairman, Hart ; F. A. Reetz,
Shelby, and M. C. Wood, Hart.

Medical Society of North Central Counties (Otsego-
Montmorency- Crawford- Osceola- Roscommon - Oge-
maw-Gladwin-Kalkaska) — C. G. Clippert, Grayling,
Chairman ; G. L. McKillop, Gaylord, and R. J. Beeby,
W. Branch.

Ontonagon — E. J. Evans, Chairman, and F. W. McHugh
of Ontonagon, and J. L. Bender, Mass.

Ottawa — E. H. Beernink, Grand Haven, Chairman ;

Wm. Westrate, Holland ; Wm. Winters, Holland.
Saginaw — S. A. Sheldon, L. D. Gomon, and H. J.
Meyer, all of Saginaw.

Sanilac — R. K. Hart, Croswell, Chairman; H. V. Nor-
gaard, Marlette ; G. C. Robertson, Sandusky.
Shiawassee — J. J. Haviland, Chairman ; J. S. Janci, and
H. A. Hume, all of Owosso.

St. Clair — Geo. Waters, Chairman ; D. W. Patterson,
J. H. Burley, all of Port Huron.

St. Joseph — J. W. Rice, Sturgis, Chairman; R. A.

Springer, Centerville ; L. K. Slote, Constantine.
Tuscola — O. G. Johnson, Mayville, Chairman; L. L.

Savage, Caro ; E. C. Swanson, Vassar.

Van Buren — Chas. Ten Houten, Chairman, Paw Paw;
Arthur A. McNabb, Lawrence; J. F. Itzen, South
Haven.

Washtenaw — M. E. Soller, Ypsilanti, Chairman; Paul
Bassow, Ann Arbor, and Richard Baugh, Milan.
Wayne — C. D. Moll, Chairman ; Carl Hanna, E. F.
Draves, O. A. Brines, all of Detroit ; T. K. Gruber,
Eloise, and T. G. Amos, Detroit.

Advisory — F. E. Winter, M.D., Lt. Colonel, Medical
Corps, U. S. Army, Station Hospital, Fort Wayne,
Detroit — J. E. Malcomson, M.D., Lt. Commander,
Medical Corps, U. S. Navy, Detroit.
Wexford-Missaukee — J. F. Gruber, Chairman; Lau-
rence Showalter, and M. R. Murphy, all of Cadillac.

73

MISCELLANEOUS

The Mary E. Pogue School

For Exceptional Children

DOCTORS: You may continue to super-
vise the treatment and care of children
you place in our school. Catalogue on
request.

WHEATON, ILLINOIS

85 Geneva Road Telephone Wheaton 66

COUNTY SECRETARIES CONFERENCE

Sunday, January 19, 1941

10:00 a.m. to 4:00 p.m.

Olds Hotel, Lansing

Horace Wray Porter, . M.D., Jackson, Chairman of
Secretaries, Presiding

Morning Program

1. Welcome by Harold W. Wiley, M.D., Lansing, Pres-
ident, Ingham County Medical Society.

2. “The Future in Legislation” (10 minutes).

By L. Fernald Foster, M.D., Bay City, Secretary,
M.S.M.S.

3. “Michigan Medical Service” (10 minutes)

By Henry R. Carstens, M.D., Detroit, President-
Elect, M.S.M.S.

4. “Medical Preparedness” (10 minutes)

By Lt. Col. Harold A. Furlong, M.D., Lansing,
Medical Board, State Selective Service Headquar-
ters.

5. “How to Make Your County Medical Society More
Influential and Successful” (20 minutes)

By H. Van Y. Caldwell, Cleveland, Executive Sec-
retary, Academy of Medicine of Cleveland.

Noon-Day Dinner
1 :00 p.m.

“Michigan’s New Intangibles Tax Law”

By Joseph H. Creighton, Manager, Intangibles Tax
Division, State Tax Commission, Lansing.

Afternoon Program

Joint Meeting with State and County Health Officers

Paul R. Urmston, M.D., Bay City, President, M.S.M.S.,
presiding

1. “Industrial Health in Relation to National Defense”
(10 minutes)

By K, E. Markuson, M.D., Lansing.

2. “Immunization Schedule” (10 minutes)

By W. C. C. Cole, M.D., Detroit.

3. “Tuberculosis Case Finding” (10 minutes)

By A. W. Newitt, M.D., Lansing.

4. “New Five-Day Treatment for Syphilis” (10 min-
utes)

By L. W. Shaffer, M.D., Detroit.

Discussion Period led by H. Allen Moyer, M.D.,
Lansing, State Health Commissioner.

DO NOT FORGET YOUR POSTGRADUATE
PROGRAM FOR 1941

Intramural Courses

Allergy

Anatomy*

Diseases of Blood and Blood-forming Organs

Diseases of Cardio-vascular System

Diseases of Genito-urinary Tract

Electrocardiography

Gastroenterology

Gynecology and Obstetrics

Laboratory Technique

Neurology and Psychiatry

Nutritional and Endocrine Problems

Ophthalmology and Otolaryngolog>-

Pathology

Pediatrics

Proctology

Roentgenology

Summer Session Courses

Extramural Courses

March 24-April 18
Ann Arbor

Battle Creek-Kalamazoo

Bay City

Flint

Grand Rapids
Lansing-Jackson
Traverse City-Manistee-
Cadillac-Petoskey
Alarquette
Mount Clemens

The Announcement of Courses will be mailed to
all members in January, and further details will appear
in the February issue of The Journal. Requests should
be addressed to the Department of Postgraduate Medi-
cine, University Hospital, Ann Arbor, Michigan.

*The course in Anatomy will be given on Wednesdays through-
out the second semester, beginning February 12, at 1:00 P.M.,
at the University of Michigan.

In Lansing

HOTEL OLDS

Fireproof

400 ROOMS

74

Jour. M.S.M.S.

WEHENKEL SAI^ATORIEM

A MODERN, comfortable sanatorium adequately equipped for all types of medical and
surgical treatment of tuberculosis. Sanatorium easily reached by way of Michigan
Highway Number 53 to Corner of Gates St., Romeo, Michigan.

For Detailed Information Regarding Rates and Admission Apply

DR. A. M. WEHENKEL) Medical Director, City Offices, Madisoo 331Z*3

worth while laboratory exam-
inations; including —

Tissue Diagnosis

The Wassermann and Kahn Tests

Blood Chemistry

Bacteriology and Clinical Pathology

Basal Metabolism

Aschheim-Zondek Pregnancy Test

Intravenous Therapy with rest rooms for
Patients.

Electrocardiograms

Central Laboratory

Oliver W. Lohr, M.D., Director

537 Millard St.

Saginaw

Phone, Dial 2-3893

The pathologist in direction is recognized
by the Council on Medical Education
and Hospitals of the A. M. A.

J.^NUARY, 1941

I

my basis. Con'i

rniUicuric.

:".«n ®®'

Say you saw it in the Journal of the Michigan State Medical Society

75

86c out of each $1.00 gross income
used for members benefit

PHYSICIANS CASUALTY ASSOCIATION
PHYSICIANS HEALTH ASSOCIATION

Hospital, Accident, Sickness

INSURANCE

For ethical practitioners exclusively

(52,000 Policies in Force)

LIBERAL HOSPITAL EXPENSE
COVERAGE

$5,000.00 ACCIDENTAL DEATH

$25.00 weekly indemnity, accident and sickness

$10,000.00 ACCIDENTAL DEATH

$50.00 weekly indemnity, accident and sickness

$15,000.00 ACCIDENTAL DEATH

$75.00 weekly indemnity, accident and sickness

For
$10.00
per yeai

For
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per yea

For
$66.00
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For
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per yeai

38 years under the same management

$1,850,000 INVESTED ASSETS
$9,500,000 PAID FOR CLAIMS

$200,000 deposited with State of Nebraska for pro-
tection of our members.

Disability need not be incurred in line of duty — benefits
from the beginning day of disability.

Send for applications, Doctor, to

400 First National Bank Building Omaha, Nebraska

EXCLUSIVELY for the TREATMENT

OF

ACUTE and CHRONIC ALCOHOLISM

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A. JAMES DeNIKE, M.D.

Medical Superintendent

DeNIKE sanitarium, Inc.

Established 1893

READING NOTICES

THE "CONTINENTAL" BREAKFAST

In far too many homes, a breakfast of a roll and a
cup of coffee is the fare for children as well as adults.
Woefully deficient in vitamins and minerals, such a
meal furnishes little more than a small amount of
calories. A dish of Pablum and milk, however, is just
as easily prepared as a “continental breakfast,” but
furnishes a variety of minerals (calcium, phosphorus,
iron, and copper) and vitamins (Bi and G) not found
so abundantly in any other cereal or breadstuff. The
addition of a glass of orange juice and one Mead’s
Capsule of Oleum Percomorphum can easil)' build up
this simple breakfast into a nourishing meal for the
children of the family as well as the adult members.
It is within the physician’s province to inquire into
and advise upon such nutritional problems, especially
since Mead Products are never advertised to the public.

SODIUM AMYTAL

The value of the sedative and hypnotic properties
of Sodium Amytal (Sodium Iso-amyl Eth^l Bar-
biturate, Lilly) in surgery, obstetrics, and internal medi-
cine is now well established.

In surgery the use of Sodium Amytal by mouth
as preliminary medication before general anesthesia
has greatly reduced the pre-operative anxiety of the
patient, lessened the amount of anesthetic, and dimin-
ished the unpleasant postoperative symptoms.

The medical applications of the sedative, hypnotic,
and anticonvulsant properties of Sodium Amytal are
many, as is illustrated by its employment in simple
insomnia, hysteria, neurasthenia, thyroid disease, chorea,
and certain of the psychoses. To these should be added
its use in the treatment of nausea and vomiting, sea-
sickness, and migraine. In addition it has proved effec-
tive in the convulsions which may occur in tetanus,
rabies, status epilepticus, meningitis, and eclampsia,
and as an antidote against overdosage of certain of
the convulsant poisons.

TRANSPARENT WOMAN DEDICATED
AS PERMANENT EXHIBIT

After visiting cities from coast to coast on its
public health educational tour during the last four
years, where it was exhibited before important medi-
cal groups and to the laity under the sponsorship of
various medical societies and Academies of Medicine,
the Transparent Woman exhibit, sponsored by S. H.
Camp & Company, was donated to the Medical Sec-
tion of the Museum of Science and Industr}-, Chicago.

It is estimated that approximately eight million per-
sons, including many thousands of physicians, viewed
the exhibit on its tour of the nation.

Dedication ceremonies, which took place recently, were
broadcast over NBC’s national Blue network and par-
ticipating in the program were Dr. Morris Fishbein,
editor of the Joiinial of the American Medical Asso-
ciation, Dr. Eben J. Carey, curator of the Medical
Section of the Museum and Dean, School of Medicine,
Marquette University, Major Lenox R. Lohr, president
Chicago Museum of Science and Industry, and Air.
S. H. Camp. Several hundred notables and distin-
guished physicians were present.

76

Say you saw it in the Journal of the Michigan State Medical Society

louR. M.S.M.S.

|)|tOr{SSIOHAlPllOTOOH

A DOCTOR SAYS:

“I have carried insurance zuith
your Company over thirty years, but
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is a background of

Precise manufacturing methods in-
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Controlled laboratory investigation

Chemical and biological control of
each lot produced

Extensive clinical application

Thirteen years’ acceptance by the
Council of Pharmacy and Chem-
istry of the American Medical
Association

A booklet summarizing the impor-
tant reports on Mercurochrome and
describing its various uses will be
sent to physicians on request.

Hynson, Westcott & Dunning, Inc.

BALTIMORE, MARYLAND

OR safety and reliability use composite Radon seeds in your
cases requiring interstitial radiation. The Composite Radon
Seed is the only type of metal Radon Seed having smooth,
round, non-cutting ends. In this type of seed, illustrated
here highly magnified. Radon is under gas-tight, leak-proof
seal. Composite Platinum (or Gold) Radon Seeds and
loading-slot instruments for their implantation are available
to you exclusively through us. Inquire and order by mail,
or preferably by telegraph, reversing charges.

THE RADIUM EMANATION CORPORATION

GRAYBAR BLDG.

Telephone MO 4-6455

NEW YORK, N. Y.

jANQAK'r', 1941

Say you sazo it in the Journal of the Michigan State Medical Society

77

Physicians' Service Laboratory

608 Kales Bldg. —
Northwest corner of
Detroit, Michigan

Kahn and Kline Test
Blood Count

Complete Blood Chemistry
Tissue Examination
Allergy Tests
Basal Metabolic Rate
Autogenous Vaccines

^6 W. Adams Ave.

Grand Circus Park

CAdillac 7940

Complete Urine Examina-
tion

Ascheim-Zonde

(Pregnancy)

Smear Examination
Darkheld Examination

All types of mailing containers supplied.
Reports by mail, phone and telegraph.

Write for further information and prices.

The Bancroft School

An Educational Foundation dedicated to
the scientific study, care and training of
the child presenting physical, mental or
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MICHIGAN PATHOLOGICAL SOCIETY

The annual meeting of the Michigan Pathological
Society was held at the University Hospital, Ann Arbor,
Michigan, on Saturday, December 14. Forty-four were
in attendance. The scientific program emphasized dem-
onstrations of various pathological manifestations of
syphilis. There were demonstrations and scientific re-
ports by Drs. C. V. Weller, W. L. Brosius, J. A. Kas-
per, F. W. Hartman, J. H. Ahronheim, G. Steiner,
O. A. Brines, R. E. Olsen, C. H. Binford, C. E.
Woodruff and W. M. German.

Dr. C. I. Owen demonstrated the lesions in a case of
tularemia and Dr. Amolsch demonstrated the pathologi-
cal process and etiological agents in' a case of syphilis
complicated by cutaneous manifestations of histoplas-
mosis.

A highlight of the program was the talk by Dr. |
John C. Bugher, formerly of Dr. Weller’s staff, on
his experiences in Columbia, in connection with the
Rockefeller Commission on Yellow Fever.

At the business meeting which followed, the follow-
ing officers were inducted into office for the ensuing
year ; President, Dr. J. A. Kasper ; president-elect.
Dr. A. Amolsch; secretary-treasurer. Dr. D. C. Beaver;
councillors. Dr. G. L. Bond and Dr. W. L. Brosius.

The next meeting will be held on February 8, 1941, at
Henry Ford Hospital in Detroit, probably jointly with
the Michigan Roentgen Ray Society.

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Tour. M.S.M.S.

Say you sazi.' it in the Journal of the Michigan State Medical Society

Tke JOUR H A L

of the Michigan State Medical Society

Issued Monthly Under the Direction of the Council
Volume 40 February, 1941 Number 2

Coronary Vascular
Heart Disease

By J. H. Musser, M.D.
New Orleans, Louisiana

John H. Musser, M.D.

University of Pennsylvania, B.S.
1905, M.D. 1908. Practiced internal
medicine until the War, when he spent
two years in the Army. After return-
ing to Philadelphia he became Associate
in Medicine at the University of Penn-
sylvania and on the staff of three of
the local hospitals. In 1925 he came
to Tulane as Professor of Medicine,
where he has been ever since. He
also is Senior Visiting Physician at the
Charity Hospital, New Orleans. Has
at various times been president of the
American College of Physicians, and
vice president of the American Medical
Association. At present is on the
American Board of Internal Medicine,
and the Council on Medical Education
and Hospitals of the A.M.A.

■ A recent editorial in the British Medical
Journal discusses the result of the postmor-
tem examination of the heart of the late Sir
James Mackenzie. Mackenzie was undoubtedly,
in the latter years of his life, the outstanding
cardiologist of the English speaking world, if
not of the whole world. He had an attack of
heart pain in 1908, when fifty-five years old,
which came on when he was at rest. This pain
was severe and continuous for two hours. He
was restless and obtained the most comfort when
moving around. He took 10 grains of veronal
and then fell asleep. The next day he was
entirely well but he did notice that the pain
could be brought on by such measures as walking
in cold air, or after a full meal. All this case
history, incidentally, is described anonymously
in his well known book on angina pectoris.
It was not until 1922, however, that these at-
tacks of cardiac pain became severe enough to
necessitate his cutting down markedly on his
activity. As result of the effect of the cold.

bleak, windy weather on his heart pain he had
to give up his work so auspiciously started at
St. Andrews and to return to London. From
that time on to his death he had several severe
attacks when peaceful and quiet. When he was
seventy-two years old, January 25, 1925, he had
an extremely severe attack and death occurred
the following day without pain.

Now Mackenzie was a man who had studied
angina pectoris the greater part of his medical
life. Angina pectoris fifteen years ago was
almost synonymous with the name of Macken-
zie and yet Mackenzie, in his various publica-
tions and books, never recognized the association
of angina pectoris and coronary closure. He
recognized the condition of status anginosus but
apparently did not appreciate this continuous
heart pain as due to cardiac infarction.

At autopsy it was found the left ventricle was
large and thick walled. In the heart muscle
were several small whitish patches of fibrous tis-
sue. In the anterior wall there was a patch of
fibrous tissue of considerable size with another
smaller area in the posterior wall about half
way between the apex and the base. At the
extreme base there was a recent hemorrhagic
infarction. There was extreme thickening of
the wall of the coronary vessels and diminution
of the lumen. The pathologist who made the
examination concludes that Mackenzie undoubt-
edly suffered from several attacks of closure
of the smaller branch of the coronary vessels,
the first occurring seventeen years before he
expired, and the last just before he died.

History

These notes from the editorial of the British
Medical Journal are significant. It was one of
the peculiar ironies of life that such an out-
standing cardiologist, living until only fifteen

99

February, 1941

CORONARY VASCULAR HEART DISEASE— MUSSER

years ago, did not recognize coronary occlusion.
It also showed that this disease, while undoubt-
edly of considerable frequency in bygone days,
nevertheless was not recognized. Although the
clinical syndrome was described by two Rus-
sians, Obratzow, and Straschesko in 1910, and in
1912 an American observer. Dr. Herrick, it is
the general concept that coronary arterial dis-
ease really had its beginning in scientific medicine
at this time but this statement applies largely
to the clinical recognition of cardiac infarction.
These two papers fell like “duds,” to quote
Dr. Herrick. There was no repercussion until
nearly six years later, when a second paper by
him aroused the interest of the clinician and
cardiologist, probably as a result of the revival
of interest in the anatomy and physiology of the
heart stimulated by the work of men as His,
Tawara, Keith and Gaskell.

At a Frank Billings Lecture delivered by Dr.
George Dock, he reviews most carefully and
deeply from the time of Heberden to Osier the
historical features of coronary closure. Dock
points out that there were many pathologists
who recognized local fibroid degeneration of the
heart muscle and the association with coronary
arterial disease. The patho.^enic relation of
the coronary arteries to heart disease Was well
understood by the pathologist of fifty years ago.
Dock questions why it was that if the patholo-
gists and those at the mortuary table knew the
importance of cardiac infarction and its depend-
ence upon coronary disease, why was it not
clinically recognized and accurately treated.
Dock’s historical paper is particularly interesting
because he is believed to have been the first man
to make the diagnosis, doing this in 1896. How-
ever, the importance of his contribution was not
recognized either by himself or by the medical
profession.

Krehl, the great German clinician, and Hu-
chard, an equally famous Frenchman, in the
first part of the present century recognized the
association of angina pectoris with coronary oc-
clusion.

To Herrick we are indebted for bringing this
condition to the attention of the medical profes-
sion. He wrote that the condition could be
recognized during life; it was not necessarily
fatal ; that it was a readily recognized clinical
entity and that the symptoms could be analyzed
so that differentiation could be made between

'm

angina pectoris and this present condition I am
discussing.

Among the names of those who have been in-
terested in this syndrome should not be forgotten
the name of Libman who, in 1919, stressed the
importance of pericardial friction rub and leu-
kocytosis as diagnostic findings of great value.

Lastly, it is appropriate that I should mention
the book, edited and written in part by Robert
L. Levy, on “Diseases of the Coronary Arteries
and Cardiac Pain.” This book, of some 400
pages, was compiled by the editor working with
a group of well known cardiologists, physiologists
and anatomists. It is most complete and of in-
estimable value.

In order that one should not think that the
subject is largely a disease in which the American
clinicians are primarily interested, I might state
that in my library I have a series of monographs
prepared by Guillermo A. Bosco of Buenos Aires
which is a tome of some 755 pages and to which
he is continually adding. Just within the last
few months I have received a fourth and a fifth
part of this book containing respectively 183 and
140 pages, indicating that South American physi-
cians are likewise taking a lively interest in this
very important disorder of the heart.

Etiology

Coronary occlusion may occur in almost any
age period, in the old individual it may be ex-
pected; in a young person however, the occur-
rence of this condition is quite unusual. Jamison
and Hauser® reported an instance in New Or-
leans of a very young man which was con-
firmed by autopsy. Levine,® in his paper which
appeared in Medical Monographs, discovered
only three of 145 people in whom the disease
developed under forty years of age. A. Stuart
Ferguson and Lockwood,^ in a review of the
literature of this condition as it occurs in young
people, in turn report a patient who recovered
who was only twenty-six years of age. How-
ever, merely because a person is young is no
reason why the syndrome should not be diag-
nosed if it is classical in character, otherwise
there is no doubt but that it will probably be
overlooked.

One of the most comprehensive statistical
studies made on this condition is a paper by
Master, Dack and Jaffe^® who report upon the
age, sex and hypertension in a group of 500

Tour. M.S.M.S.

CORONARY VASCULAR HEART DISEASE— MUSSER

patients. In this group the youngest was aged
twenty-seven, the oldest eighty-seven. The av-
erage age at the time of the first attack was 54
and the first attack occurred most commonly
in the sixth decade of life. In the several age
groups the order of frequency was as follows:
26 per cent in those in the seventh decade, 25
per cent in the fifth decade, '33.7 per cent in the
sixth decade, under forty years of age, 10 per
cent, and over seventy-nine, 5.4 per cent.

Sex

The sexual difference is marked. The males
are very much more frequently attacked than
females. Parkinson^^ states that 93 per cent of
his patients were men. Statistics collected by
the Metropolitan Life Insurance Company show
a rate in males of 16 per 100,000 as contrasted
with 3.5 among women. In Master, Dack and
Jaffe’s paper 77.4 per cent were men, 22.6 per
cent were women. Every clinician knows that
it is the man who is more frequently attacked
than the female but among those who have a
fairly large female clientele the incidence would
seem to be higher than these statistics would
imply.

Occupation

died the preceding year and summarizing the
cause of death, points out that heart disease is
the leading cause of death of physicians ; for ex-
ample, 1,585 heart deaths as contrasted with the
next most frequent cause, namely arteriosclerosis
with 453 deaths, followed by pneumonia with
370 and cancer with 357. It should be noted
that when the figures for heart disease are bro-
ken down, coronary arterial disease, either
thrombosis, occlusion or angina pectoris, resulted
in the death of 676 physicians or more than any
other one cause of death. Probably this number
would be increased considerably were there given
an exact cause of death, because “myocarditis”
which in the ultimate analysis is usually due to
coronary disease, caused 534 deaths. Then there
was a group of cases which were labeled as
“other diseases of the heart.”

Heredity

To my mind in so far as predisposing factors
other than age and sex are concerned, heredity
ranks first. Whether the constitutional make up
is responsible for the marked hereditary ten-
dencies in this disease, many patients are over-
weight which in turn in many instances is an
inheritable characteristic, or whether it is some
peculiar arrangement of the coronary vessels
which may predispose them to strain, is a debat-
able question. Dublin believes that if there is any
relationship between heredity and coronary dis-
ease it is based upon overweight because in peo-
ple who die of angina pectoris, which of course
often is coronary disease, the death rate was
twice that of those who had normal weight, two
and a half times more frequent than in those
who were underweight.

Occupation is apparently an extremely impor-
tant predisposing factor. The general concept
is that the disease is largely one which is par-
ticularly likely to attack those of the upper in-
come group, business and professional men in
other words. This contention may be substan-
tiated by the large number of doctors whose
deaths are recorded yearly, as I will mention
later, who died as result of coronary occlusion.

On the other hand, Levy^° denies this implica-
tion and in his over 2,500 necropsy studies it was
found that foremen and skilled workers showed
44 per cent coronary lesions, whereas among
executives and members of professions the per-
centage was 34.3, with manual laborers slightly
under these figures. Despite this statistical ob-
servation, when the physician glances at the
obituary columns of the Journal of the American
Medical Association he is astounded at the num-_^
ber of deaths that occur in the

sion as result of coronary occlus^^vdf' infarction. ^ ^

It has become the commones^ ^use . Hy^^ension. — The question of hypertension
among doctors. A recent editllriaH in ^las agitqjted medical men for a long period of

nal, discussing the obituary o\physicians who time. However, hypertension is by no means a

Chronic Disease

Diabetes. — I will not comment upon diabetes
except to call attention to the fact frequently
reiterated and repeated, that arterial disease
anywhere in the vascular tree is common in the
diabetic individual, so that it is natural to ex-
pect the coronary vessels would not escape the
general vascular involvement. Furthermore,
ese people are often a more advanced age

!;ens^on.-

February, 1941

OF M

EO\^.

101

CORONARY VASCULAR HEART DISEASE— MUSSER

sine qua non for the diagnosis of the condition.
Particularly does this statement apply to men
because in the statistics quoted, as compiled by
Master et al.,’^^ hypertension was noted in only
62 per cent of the cases as occurring in men
and in approximately four-fifths of the women.
It may be seen that it is definitely higher in
women but not necessarily is a relatively low
blood pressure unusual in a man who has this
condition.

Other Factors.- — Other factors such as infec-
tions, notably syphilis, the use of alcohol and to-
bacco or caffein, probably, play only a minor role
in the production of sclerosis of the coronary
vessels. The disease syphilis rarely is an etio-
logic factor of importance; were it so the death
rate from this condition, coronary occlusion,
would be very much more common than it is
among the Negro in whom the syphilitic incidence
is high, whereas the coronary occlusion rate is
low.

Pathology

Time does not permit a discussion of the
pathology in detail. I would like to call atten-
tion, however, to a splendid clinical pathologic
study made by Blumgart, Schlesinger and Davis^
which appeared in the January number of the
American Heart Journal. It is a long, lengthy
paper from which I would like to point out one
or two important conclusions. It is quite possi-
ble for a patient to develop coronary thrombosis
and myocardial infarction without any charac-
teristic clinical manifestations. If a gradual oc-
clusion develops over a period of years, during
this protracted interval of time there develops an
anastomotic circulation, so that all direct symp-
toms and signs will be absent.

In regard to the pathologic basis for conges-
tive failure, these authors note that certain areas
in the heart, undernourished as result of cor-
onary arteriosclerosis, when subjected to greater
anoxemia produced by exertion or emotion, de-
velop focal necrosis and diffuse fibrotic changes.
This replacement by connective tissue ultimately
produces myocardial weakness and finally con-
gestive failure.

The left coronary artery, shortly after its
origin from the sinus of the left posterior aortic
leaflet, divides into two main divisions, the an-
terior descending and the circumflex. The an-

terior descending branch is the artery most fre- i
quently involved. As this supplies, as it does,
the anterior wall of the right and left ventricle
and part of the interventricular septum, it is
natural that one of the outstanding physical find-
ings, namely a pericardial friction rub which so
often determines definitely the diagnosis, is :
likely to be produced in some instances in which
the area of infarction is sufficiently large to
extend out to the parietovisceral pericardium.
Likewise involvement of the interventricular sep-
tum from time to time will produce heart block,
although this complication is relatively rare.
Usually it is the right coronary that will bring
about this particular condition in 93 per cent
of cases, according to Ball.^ As a matter of fact
complete auriculoventricular block from occlusion
of the usually involved vessel is apparently rare,
as substantiated by a recent paper by Heninger
and Dickens.®

Symptomatology

It is the general concept that an occlusion of
the coronary artery which produces symptoms,
is precipitated by some extrinsic factor, be this
exercise, excitement, emotion, eating or what
not. As was pointed out in a review of the
literature by GraybieP “one cannot help be-
ing impressed with the fact that many persons
with marked coronary atherosclerosis never suf-
fer acute coronary occlusion and cardiac infarc-
tion. This being so, there must be precipitating
factors of coronary occlusion; the occlusion can-
not be regarded as a purely fortuitous event.”
Be that as it may, every clinician is familiar with
the patient who has had his first attack at night
during sleep or while completely at rest. If the
patient is asleep it might be assumed that a
dream of some kind or another may have altered
the dynamics of the cardiac circulation to pro-
duce the occlusion.

I will not endeavor to recite to you the usual
characteristic symptoms of coronary occlusion.
They have been dwelt upon so frequently and
reiterated so many times that every one is fa- j
miliar with the syndrome of heart pain, followed j
by shock, succeeded by fever, leukocytosis and
shortness of breath. I would like to point out,
however, that pain may be entirely absent or it
may be so slight that it escapes the patient’s
attention. This, of course, is unusual but given '
an individual who, without cause, may develop

102

Tour. M.S.M.S.

CORONARY VASCULAR HEART DISEASE— MUSSER

acute dyspnea or pulmonary edema, even if this
individual is middle aged, has some slight hyper-
tension and is somewhat overweight but who
does not have previously known myocardial or
endocardial disease notably of the aortic valves
nor does he have marked hypertension, it is quite
possible that this patient will have or has had
coronary' occlusion with infarction. Substernal
pain, as pointed out by Herrmann and Decherd,^
in an analysis of some 230 cases, may be quite
atypical. Of the 127 patients in whom the symp-
tom of pain was analyzed, twenty-six of them
had atypical substernal pain and quite a group
had pain which was referred only to the epi-
gastrium, a well known clinical observation which
sometimes still confuses and makes possible the
occasional reporting of a death of a patient as
being due to “acute indigestion” when it is the
result of coronary' disease. Pain may be referred
to the right shoulder only, to the neck, to the
interscapular region or even to the right chest
and leg. Of course pain is undoubtedly the
most important diagnostic expression of the dis-
ease but it must not be forgotten that the con-
dition may develop without even discomfort.

Differential Diagnosis

In this connection in conjunction with the
symptom of pain, I would like to point out that
the differential diagnosis of the pain of angina
pectoris and the pain of coronary occlusion is
of extreme importance not only from the prog-
nostic standpoint but also from the viewpoint
of the immediate and later care of the patient.
It is for this reason that I am presenting a
tabulation, as compiled by my associate, W. A.
Sodeman, of the important diagnostic points
which may help differentiate these two condi-
tions. Incidentally, it will demonstrate also the
important diagnostic features connected with the
two conditions.

Prognosis

Personally I am of the impression that the
cumulative data which have to do with the ul-
timate outcome in coronary occlusion are worth-
less. I say this advisedly and for several rea-
sons. Statistics that have been compiled have to
do with patients who have acute atypical at-
tacks. The experience of all clinicians has been
that it is by no means infrequent for people
to have mild unrecognized attacks, sometimes

DIFFERENTIAL DIAGNOSIS OF ANGINA PECTORIS
AND THE PAIN OF MYOCARDIAL INFARCTION

Coronary

Angina Pectoris

Thrombosis

Onset

During exertion

Usually during
rest or sleep

Attitude

Immobile

Restive ; may walk
about

Site of pain

Sternum to arm

Sternum or lower

Duration

Minutes

Hours or days

Dyspnea

Absent

Usually severe

Vomiting

Rare

Common

Shock

Absent

Present

Sweating

Slight

Severe

Facies

Normal

Ashen pallor

Pulse

Unchanged

Feeble, often rapid

Temperature

Unchanged

Subnormal, then
febrile

Blood pressure

Unchanged or
raised

Lowered

Heart failure

Absent

Often follows

Heart sounds

Unchanged

Gallop rhythm,
friction

Leukocytosis

Absent

Present

Electrocardio-

May be abnor-

Often diagnostic

gram

mal

Action of nitrites

Often relieved

No relief.

discovered accidentally as result of a coronary
electrocardiogram. Sometimes these minimal or
minor attacks are only recalled by the patient
when he has had a major attack and the history
is gone into carefully. Undoubtedly there are
many patients who do have attacks which are
recognized and who continue to go about ac-
tively and vigorously. Parenthetically I might
remark that Lewis, for example, reported on
a patient he had seen some seven years prior
to the appearance of this patient and who since
that time had done most strenuous activities of
all kinds, from flying at altitudes of 15,000 feet
to skiing each winter and dancing ad lib. It
is possible to generalize to this extent, that the
older the patient is the more likely that patient is
to succumb and the younger the age of onset
the greater is the life expectancy.

Another statistical study, which in this instance
has to do with what occurs to the man who
has had an acute coronary arter}^ occlusion, is
that of Master and Dack.^^ These observers
sent out a questionnaire to a series of 415 pa-
tients ; 185 of whom were private patients and
230 ward patients. The purpose was to deter-
mine how much could be done and was being
done by a person who had sustained and survived

Febru.ary, 1941

103

CORONARY VASCULAR HEART DISEASE— MUSSER

an acute attack. The authors showed that 53
per cent of patients returned to work after re-
covering from their occlusion, 57 per cent of
whom were private patients and 50 per cent
were ward patients. It is of some interest to
note that 84 per cent of professional people re-
turned to work and particularly physicians. It
is not surprising that age played an important
role in the ability of the person to resume his
usual occupation. As with the prognosis, so in
this study it is found that the younger the indi-
vidual the more likely was he to return to his
previous work status. Some of these patients
never did stop work, a considerable per cent
(48) of them stopped for less than three months.
From three to six months was the time period
of convalescence from the attack of 22 per cent.
One individual did not return to work for six
years. Rather interesting that a certain num-
ber of the group did not return because they
were advised not to, although apparently they
were in good condition, and a fairly consid-
erable number, more than those who were physi-
cally unable, did not start working because of
disability insurance. The chief cause of the in-
ability to return to work was a physical dis-
ability resulting either from angina pectoris,
dyspnea or from weakness. The concluding
paragraph comments to the effect that ‘‘an attack
of acute coronary occlusion in itself is not suf-
ficient reason for permanent disability. Com-
plete recovery and full or partial economic resti-
tution are common. Heart failure or a severe
anginal syndrome is evidence of complete dis-
ability.” These statements confirm that which
is well known and bring further comfort to the
man who has had coronary occlusion, that his
attack is not necessarily associated with eco-
nomic dependence.

Treatment

The treatment logically divides itself into three
phases: (1) immediate, (2) mediate, and (3)
later.

For the immediate treatment the patient should
be handled as any patient who has shock —
morphine, warmth, absolute quiet but avoiding
stimulation. This applies particularly to cardiac
stimulants. Be satisfied with giving glucose
solution intravenously and letting the glucose
act as a maintainer of cardiac reserve. Avoid
digitalis and its products unless it looks as if

the patient is going to die of heart failure, under
which circumstance make use of ouabain. In
giving the sugar solution give it by mouth, ap-
proximately 1,200 c.c. in twenty-four hours.
If it is absolutely essential to give fluid into the
vein, then inject not more than 100 c.c. of 50
per cent glucose. Very generally there has come
into use a drug, quinidine, in order to prevent
the fatal complication of ventricular fibrillation ;
give 5 grains (.32 mg.) every three hours for
several days. Use adrenalin or ephedrine only
as a last resort. Oxygen should, by all means,
be used and if the patient is breathing with dif-
ficulty and there are basal rales, tachycardia and/
or gallop rhythm. The oxygen want should be
met by external administration.

The mediate treatment consists of absolute
rest for a period of at least three weeks. The
patient should be kept in bed and restlessness
should be controlled by sedatives. In order to
avoid venous thrombosis the lower extremities
should be moved from time to time but this
should be passive rather than active. The xan-
thine preparations are started at this time. In-
cidentally, caffein sodium benzoate intramus-
cularly is the best stimulant during the period
of shock. Aminophyllin is begun and is con-
tinued indefinitely, four tablets a day. The pa-
tient should be allowed to get up gradually in
about six weeks. After three weeks in bed the
patient can move about rather freely but should
not even have toilet privileges.

Subsequent treatment should aim to get the
patient back to a normal life. For a period
of six months active exercise is interdicted and
for a year the patient should avoid excesses in
everything, eating, drinking, physical or sexual.
I would urge above everything else that this
patient be encouraged to get back to a normal
life and call attention to the figures I quoted
in the first part of this paper which showed
that a very large number of patients, if they do
not have fear of sudden death thrust upon them
at all times, are able to, can and will get back to
a relatively normal existence.

Summary

I have given you a rather fragmentary presen-
tation of an extremely common disorder. Much
has been written about the condition clinically
and great has been the experimental work in
the past twenty years, consequently much is

104

Jour. M.S.M.S.

UNX'SUAL HYPERTEXSIOX— STALKER

known about a condition about which, up until
1918 following the second paper of Dr. Her-
rick of Chicago, practically nothing was known.
It would be impossible in a short time to pre-
sent the innumerable facts concerning coronary
occlusion. Many questions may arise in the

minds of my auditors as they listen to the few
remarks that I have just made, but they can
not be answered in a short dissertation on a
subject which is book length in extent.

References

1. Ball, D.: The occurrence of heart block in coronary

artery thrombosis. Am. Heart. Jour., 8:327, 1932.

2. Blumgart, H. L., Schlesinger, M. _ J., and Davis, D. :
Studies on the relation of the clinical manifestati9ns of
angina pectoris, coronary thrombosis arrd myocardial in-
farction to the pathologic findings. Am. Heart Jour., 19:1,
1940.

3. Editorial : Obituaries of phvsicians published in 1939.

Jour. A.M.A., 114:1362, 1940.

4. Ferguson, A. Stuart, and Lockwood, J. R. : Coronary

occlusion in young adults: Review of literature with re-

port of case aged twenty-six. New York State Jour.
Med., 39:1618, 1939.

5. Graybiel, A.: Diseases of the heart: A review of sig-
nificant contributions made during 1939. Arch. Int. Med.,
65:1053, 1940.

6. Heninger, B. R., and Dickens, K. L. : Complete auriculo-

ventricular block following coronary occlusion: A case

report. Ann. Int. Med., 13:1081, 1939.

7. Herrmann, G. R., and Decherd, G. M., Jr.: Acute coro-

nary occlusion with cardiac infarction. South. Med. Jour.,
32:696, 1939.

8. Jamison, S. C., and Hauser, G. H. : Angina pectoris in

youth of eighteen. Jour. A.M.A., 85 :1398, 1925.

9. Levine, S. A.: Medical Monographs. Baltimore: Williams

and Wilkins Co., 16:15, 1929.

10. Levy, R. L. : Diseases of the Coronary Arteries and

Cardiac Pain. New York: Macmillan Co., 1936, p. 203.

11. Lewis, W. H. : Coronary occlusion: A report of unusual

activities after recovery. Jour. A.M.A., 114:484, 1940.

12. Master, A. M., and Dack, S. : Rehabilitation following

acute coronarj' artery occlusion. Jour. A.M.A., 115:828,
1940.

13. Master, A. M., Dack, S., and Jaffe, H. L. : Age, sex
and hypertension in myocardial infarction due to coronary
occlusion. Arch. Int. Med., 64:767, 1939.

14. Parkinson, J., and Bedford, D. E. : Cardiac infarction and

coronary thrombosis. Lancet, 1 :4. 1928.

WARRIORS AGAINST DISEASE

American medicine, as an authority recently observed,
has a weak spot. It is not a weakness affecting
the patient — the sick man or woman anxiously seeking
a return to health. Curiously enough, this weakness
has helped the patient — for the weakness lies in the
fact that the medical profession has been so busy fight-
ing disease in experimental laboratories as well as at
the bedsides of the ill that it has found little time to
tell the public of its tremendous achievements.

The undeniable record is there for all who wish to
read it. And it tells, through the figures, a dramatic
and inspirational story of an endless battle against
disease and suffering and death.

That battle has won victory after victor}’. In the
period of a century and a half in this country, the
life expectancy of man has nearly doubled from thirty-
five to sixty-two years. During that time, typhus, once
one of the greatest killers, has all but disappeared.
Smallpox and diphtheria, dreaded specters not so long
ago, have been robbed of their terrors. Other great
scourges — typhoid, diabetes, tuberculosis — have been
brought under control, and their mortality rates steadily
reduced. . . .

Medicine is not an industry. But, like industry, it has
rendered its greatest ser\’ice to the people under a
system which places no brakes upon the achievements
of the individual, and which encourages any man, in
any field, to develop his talents to the utmost. — Lapeer
Comity Press, Lapeer, ^Michigan, Jan. 8, 1941.

Febri-.^ky, 1941

Unusual Hypertension

A Case of Ten Years'
Duration*

By Hugh Stalker, M.D., F.A.C.P.

Detroit, Michigan

Hugh Stalker, M.D.

M.D., Harvard University Medical School,

1924. Fellow, American College of Physi-
cians. Diplomate of the American Board of
Internal Medicine. Instructor in Medicine at
the Wayne University Medical School. Staff
member of Harper and Children’s Hospitals,

Detroit, and The Cottage Hospital, Grosse
Pointe Farms. Member, Michigan State Med-
ical Society.

■ Since it has been estimated that nearly
100,000 people die annually in the United
States as the result of heart failure because of
hypertension and that many more die from cere-
bral accidents and renal insufficiency, it is well to
pause and give thought.

The systolic pressure in established hyperten-
sion varies from 150 to over 300 millimeters of
mercuiy^ but it is usually about 200 ; the diastolic
pressure varies from 90 to 180 but is usually
about 110. The pressure readings (especially
systolic) vary greatly among different individuals
and on different occasions in the same individual.
Repeated measurements must often be made be-
fore the customary blood pressure levels for a
patient are discovered, uninfluenced by excite-
ment, exertion, or fatigue. A very high diastolic
pressure is usually a bad sign and a constant
finding of such a pressure over 130 millimeters of
mercury means that but a few months or years
of life remain.

The following history’ is of a patient who first
came to us in 1928, with a systolic blood pressure
of 300 plus. Her blood pressure has remained
high and now, eleven years later, shows the same
systolic pressure ; her retinae show remarkably
few pathological changes and her kidney function
is very good.

Case History

A colored woman, now fifty-five years old, was first
seen by us in 1928 when she complained of dyspnea on
exertion and dizziness w’hich she had experienced since
1924. In 1928 she started to have headaches. She had
black spots in front of her eyes and became dizzy when
reading: there was no epistaxis.

Family History. — Mother and father died of strokes,
the former at fifty and the latter at sixty. Her first

*From the Cardiologv' Clinic, Harper Hospital.

105

UNUSUAL HYPERTENSION— STALKEr

1928 1929 1930 1931 1932 1933 1934-1936 1937 1938 1939

husband is dead. Her second husband is living and
well. One son living but tuberculous.

Physical Examination. — Weight 170 pounds. There
were many snags of teeth, enlarged tonsils, marked
pulsations of carotids and in supra-sternal notch, some
rales at the bases posteriorly, the heart was enlarged
to the left, there was a systolic murmur at the base and
both systolic and diastolic at the apex. The blood pres-
sure was 300 plus/110. There was no edema of the ex-
tremities. Rectal examination showed external and in-
ternal hemorrhoids. The blood and urine were negative.
Blood non-protein nitrogen 30 mgs., and blood sugar
0.95 mgs.

X-ray Examination. — On March 30, 1929, the heart
showed definite left-sided enlargement. Aortic shadow
of normal size. No substernal thyroid. Slight increase
in root infiltration.

Electrocardiogram. — Regular rhythm. Sinus arrhyth-
mia. Alarked left axis deviation. Inversion of T 2 and
3. Flat T 1. S-T 1 and 2 depressed. S-T 3 elevated.
Conclusions : Alarked myocardial damage.

Immediate Progress. While she was in the hospital
with rest, diet, sodium bromide and chloral hydrate,
and erythroltetranitrate, the blood pressure dropped to
170/90. Her menopause was about the middle of 1930.
The patient was then seen at intervals in the outpatient
department to October, 1933, and it was always noted
that her blood pressure was in the hypertensive group.
Once she complained of numbness of the left side of
the face, the left arm and leg, but there was no dis-
turbance in sensation. There was occasional shortness
of breath and at different t'mes she was given digitalis

but never continued with it. Her electrocardiograms
showed progressive myocardial degeneration.

Fundi. — On October 10, 1930, the fundi were within
normal limits. Some of the vessels in the region of the
discs showed presence of slight sheathing; some of the
arteries were tortuous ; venous pulsations presented a i
picture suggestive of arteriosclerosis. '

Further Progress. We lost sight of the patient until •
February, 1937, at which time she showed a blood pres- i
su'.e of 280/100. The red blood cells were always essen- ■
tially normal and there was only a slight reduction in i
the amount of hemoglobin. The blood non-protein ni-
trogen was always normal and the blood Wassermann
test was always negative. She complained occasionally !
of being dizzy, tired, and listless. Her weight became '
progressively less. In 1938 there was a question of
numbness of the left side of the bod}' which appeared
to increase. A neurologist made a diagnosis at that t'me
of small but recurrent right sided cerebral hemorrhages.
Occasionally she acknowledged some relief from phle- ;
botomy and also was given sodium nitrites, capsules of
theobromine and phenobarbital, digalen, and epsom
salts. Her second husband died in October, 1938. In
December her subjective symptoms were some short-
ness of breath, dizziness, and headache. There was no
edema of ankles and feet. An electrocardiogram in
Alay, 1939, gave the appearance of an old posterior
infarction.

Fluoroscopy. — On Alarch 30, 1939, a fluoroscopic
study of the chest showed normal position of the dia-
phragm leaves with clear costophrenic sinuses and clear
lung fields. The heart was enlarged in its transverse i

106

louR. Al.S.Af.S.

UNDESCENDED TESTIS— BAILEY

diameter with particular enlargement in the left ven-
tricular area which extended downward and towards the
left and also posteriorly to a marked degree. No intra-
cardiac calcification was demonstrable. The beat seen
along the left border was regular and of small ampli-
tude. There was very marked dilatation of the thoracic
aorta although there was no aneurysmal dilatation at
any point. The aorta exhibited a marked pulsation
throughout. A radiograph taken at the six-foot dis-
tance showed considerable calcification in the trans-
verse arch and the following measurements :

Internal diameter of chest 27.1 cm.

ML 10.8 cm.

MR 5.0 cm.

G V 7.6 cm.

Kymography. — A kymographic study in the antero-
posterior and left lateral projections showed a regular
cardiac beat of moderate rate and a very small ampli-
tude in the left ventricular area suggesting myocardial
damage. The pulsations of the aorta were of unusually
large amplitude.

Eyes. — On June 14, 1939, vision in right eye was 20/
100; left eye, 20/30. Pupils reacted to light and ac-
commodation. Fundi revealed no evidence of hemor-
rhages. Vessels were quite small and wavy towards
their periphery. They also showed white streaks along
the surface but no other evidence of hypertension. Disc
normal on , appearance. No lens changes. The blood
pressure in the right arm was 300 plus/110; in the left
arm 290/110. Weight 122 pounds.

Discussion

A case of extreme systolic hypertension is pre-
sented in a colored female which was first diag-
nosed two years before the menopause. It
has progressed for eleven years most of that
time under observation with very few signs of
heart failure or retinal changes and good kidney
function. She has shown no signs of hyperthy-
roidism/ large vessel sclerosis, coarctation of the
aorta, or arteriovenous communication and psy-
chically is a quiet, rather phlegmatic, individual.
(Recently she asked my advice about remarry-
ing). Hence the diagnosis must primarily be
essential hypertension.

References

1. Palmer, R. C. ; Personal communication.

2. White, Paul D. : Heart Disease. 2nd Edition. The Mac-

millan Company, 1937, p. 314.

The attention of the medical profession is directed to
the appearance of a special issue of Harofe Haivri
(The Hebrew Medical Journal), a semi-annual publica-
tion, edited by Dr. Moses Einhorn. This volume com-
memorates the thirteenth anniversary of this journal
and is dedicated to Prof. Sigmund Freud.

February, 1941

The Undescended Testis

By Louis J. Bailey, M.D., M.Sc. (Med.), F.A.C.P.

Detroit, Michigan

Louis J. Bailey, M.D.

M.D., Wayne University College of Medi-
cine, 1925. M.Sc. (Med.). University of Penn-
sylvania, 1939 for grad'uate work in Infernal
Medicine. F.A.C.P., Certified American Board
of Infernal Medicine. Instructor in Clinical
Medicine at Wayne University. Member of
the Michigan State Medical Society.

■ In the descent of the testis the gubernacu-
lum testis is not attached to the scrotum but
to the peritoneum and to the fascia which sur-
rounds the process of peritoneum which comes
to be known as the processus vaginalis. The
gubernaculum testis is also attached to the pubic
spine and the perineum. Therefore, while a
prominent role has conventionally been assigned
the gubernaculum in guiding the testis to its
normal scrotal position, it can only do so inso-
far as the processus vaginalis develops normally,
descends normally through the inguinal canal and
into the scrotum.

The physiological forces which control the
development and normal direction of the proces-
sus vaginalis are not at all certain but it was
proved experimentally in 1932® that the testes
of immature rats and monkeys could be caused
to descend by the administration of extracts of
the anterior pituitary or pregnancy urine. The
author noted in a series of experiments on rats
in 1933 that the immature male was a better
animal upon which to demonstrate the presence
of A.P.L. than the immature female of the same
age by virtue of the speed with which the testes
descended after the injection of pregnancy urine
or extracts containing A.P.L. Coincidentally, the
seminal vesicles increased several times in size
These animals were twenty-one to twenty-five
days old and younger animals were not used;
but it is known from reports in the literature that
more immature animals are more refractory to
anterior pituitary or anterior pituitary-like
hormones.

So far as I am aware, the human infant is
the only mammal to exhibit descent of the
testicle normally at birth. This fact has been
quoted to indicate that the organ has been
acted upon prenatally by the hormones circu-
lating in the mother’s blood, i.e., anterior pitui-

107

UN DESCENDED TESTI S— P.AI LEY

tary-like hormone, to cause descent, for the
human female is the only one in whom this
hormone can be demonstrated in the urine dur-
ing pregnancy.

A similar hormone is demonstrable in the
blood of the pregnant mare for a few weeks dur-
ing pregnancy but there are some differences in
the biological behavior of A.P.L. as found in
human pregnancy urine and the hormone of
pregnant mares’ serum.

Spontaneous Descent

Tdespite the implication that the undescended
testicle will remain refractory to hormone stimu-
lation since it did not respond to A.P.L. during
intra-uterine life, we are nevertheless confronted
by the indisputable fact that the majority of un-
descended testes will descend during adolescent
years. The figures vary widely but all are
agreed that the various army statistics which in-
dicate an incidence postpubertally of two or three
cases per thousand men probably reflect the true
incidence of undescended testicle in the adult.
Therefore, Johnson,"^ who saw seventeen cases
per thousand in over thirty-one thousand prepu-
bertal boys, aptly inquires as to what happens
during puberty to the other fifteen cases per
thousand. In his five hundred and thirty-four
cases, there was spontaneous descent in three
hundred and thirteen, the age of spontaneous
descent falling between seven and seventeen years,
most being between nine and fourteen years.

Since undescended testicle is not commonly
seen in association with Frflhlich’s syndrome, it
is unfair to assume that pre-adolescent hypo-
pituitarism is commonly the cause. Nor can a
lack of A.P.L. in the mother be considered as the
reason for the failure of descent. The obvious
conclusion is that the cause rests either in the
testicle itself as a refractory effector organ or in
developmental mal-development of the processus
vaginalis and/or the gubernaculum testis.

Clinical Classification

Various classifications have been advanced,®’^”
the most useful being a clinical one

1. Those with an associated endocrinopathy.

2. Those with fixed mechanically retained
testes or ectopy.

3. Those with movable testes which may be
manipulated into the scrotum.

Treatment

Associated Endocrinopathy. — There is agree-
ment that patients presenting other evidence of
endocrine abnormality should be treated en-
docrinologically.®’®’^^’^^ Thus it follows as a mat-
ter of course that the proper hormones will be
exhibited in those patients with mental, physical
or osseous retardation irrespective of the con-
comitant presence of cr}’ptorchidism. Delay of
appearance of epiphyseal centers with or without
mental retardation will call for thyroid treat-
ment ; but the practitioner will probably prefer
to exhibit A.P.L. in the dosages to be mentioned
later if his patient is cryptorchid and not too
young. Likewise Frdhlich’s syndrome will be
treated with thyroid, diet and anterior pituitary-
like substances and if one or both testicles hap-
pen to be undescended in such a patient, descent
of the organs will be accepted as an added divi-
dend. I have not seen dwarfism in a young
boy, but I should expect that this pituitary syn-
drome would be as refractory insofar as the
gonads are concerned as it is in the young girl.

These cases frequently respond well to
growth hormones but it is the usual thing for
attempt at gonadal stimulation to fail.

M echanically Fixed Testes. — There is no hurry
in treating cases of undescended testicle un-
associated with other endocrine defects. Pre-
pubertally, the undescended testicle is no differ-
ent histologically than the normally placed
organ. Indeed, with the record of sponta-
neous descent which has been quoted one might
inquire as to whether the condition should be
treated at all. The reasons most frequently given
for early treatment, either hormonal or opera-
tive, are :

1. Histological damage to the testicle retained
after puberty.

2. The possible occurence of carcinoma.

3. The possible occurrence of infection and
injury.

The first of these is far and away the most im-
portant. Evidence that the retained testicle is
more frequently infected or more frequently the
site of carcinoma is not too conclusive.^ There
is ample evidence, however, that the retained
testicle is different histologically postpubertally
than the normal organ. Whereas at

108

Jour. M.S.M.S.

UN^DESCEXDED TESTIS— BAILEY

puberty the normally descended testis grows
sharply and develops spermatozoa, the undes-
cended organ grows slightly, develops usually
only spermatogonia, rarely spermatozoa and later
the germinal epithelium atrophies. Sterility is
the rule in bilateral cryptorchidism,^” the cause
apparently lying in the increased heat to which
the organ is subjected.^^

It would seem reasonable therefore to pre-
scribe treatment in all cases of bilateral
cryptorchidism even though the chances for
normal descent are greater than those for con-
tinued nondescent because of the loss of fertil-
ity which is bound to occur should the condi-
tion persist. Likewise, it would seem reason-
able to prescribe treatment in unilateral
cryptorchidism even though the chance of in-
jury to organs retained in the inguinal canal
be slight because hormone treatment is harm-
less and may accomplish complete results.
Further, should hormone treatment fail, we
shall have diagnosed those cases belonging in
this category of the classification, i.e., those
with mechanically fixed and retained organs.

Short of operation, the patient belonging in
this category cannot otherwise be accurately
diagnosed. It then becomes necessary to deter-
mine the age at which treatment had best be
applied. If there is no other associated en-
docrinopathy, I see no objection to waiting until
near puberty or the first years of puberty to pre-
scribe hormone treatment. In fact the statistics
relative to spontaneous descent would appear to
demand delay.

Migratory Type. — The patient belonging in the
third category of the classification, i.e., those with
migratory testes, will almost inevitably show
spontaneous descent. These cases require no
treatment, obviously. But I see no objection to
treating those in whom a low scrotal position is
never seen for the same reason already given,
viz., that one cannot positively determine whether
or not mechanical obstruction is present.

Endocrine Therapy

Having decided to treat these patients and
having decided the age limit during which treat-
ment should be prescribed as preferably nine to
fourteen years, one is faced with the necessity of
choosing the endocrine substance to be exhibited.

You will recall that anterior pituitary-like hor-
mone is thought to exert its effect upon the pa-
tient’s own pituitary gland, initiating the dis-
charge of pituitary gonadotropic hormones. Be-
cause of its ready availability this substance has
been most widely used in treatment of cr}"ptor-
chidism. In -addition, more latterly there have
been available the pituitary hormone from preg-
nant mares’ serum (Gonadogen) and one of the
testicular hormones itself, testosterone, used as
testosterone propionate. With the latter two
substances I have no experience and merely wish
to point out that the reports in the literature to
date are too meager and too unsatisfactorv to
warrant furher commenff’” and that the pituitar}'"
hormone as it is now available extracted from the
gland itself is not to be preferred over anterior
pituitar}'-like substance.^ It is therefore appar-
ent that our choice of therapeutic material is
limited to extracts of pregnancy urine (A.P.L.,
Antuitrin-S, Follutein, et cetera.).

Dosage. — A review of the literature would in-
dicate that doses of from 100 R.U. twice weekly
to from 100 or 1000 R.U. daily have been ad-
ministered. The total effective dose reported
has varied from 2400 to 7500 and

the total duration of treatment has been reported
by these same authors as from three to twenty-
five weeks, the average being about 2 months, I
am in agreement with the discussant of one of
these papers^” that our peak dose need not exceed
1500 R.U. w'eekl}^ This would mean in the case
of concentrated Antuitrin-S containing 500 R.U.
per cubic centimeter a dose of 1 c.c. three times
a week which can if you wish be given by the
parents at home similarly to the administration
of insulin to diabetic children.

This dose had best be obtained by degrees.
We do not see the local or constitutional reac-
tions with Antuitrin-S today as were seen a few
years ago when the first products were released
for commercial consumption. It is, nevertheless,
my habit to give 100 R.U. per dose during the
first week of treatment, increasing to 250 R.U,
per dose in the second week and thereafter ad-
ministering 500 R.U. per dose two or three times
a week.

Results

The results to be expected from hormone treat-
ment have been amply recorded. Permanent

Fei3ru.\ry. 1941

109

1

UNDESCENDED TESTIS— BAILEY

descent in 61 per cent of treated cases as re-
ported would appear to be entirely too high a re-
sult. As you are well aware, the literature has
constantly cautioned against including migratory
cases as cases of true cryptorchidism. Other ob-
servers have reported permanent descent in from
19 to 45 per cent of their cases.^’^’^^’^^’^^’^®

Operative Results. — Such results would appear
to indicate that operation will be necessary in
the majority of cases if a good scrotal position
is to be obtained, and I belie\'e this to be the
case. In one series of seven patients treated
surgically after failure of A.P.L. all showed
anatomical reasons for the failure. Operation
was necessary in 75 per cent of Thompson’s
cases.’^® I should like to emphasize again, how-
ever, that the use of A.P.L. pre-operatively is
valuable as an aid in the selection of cases for
surgery and as a means of enlarging the struc-
tures to be found at operation.

The results to be obtained by operation appear
to have been inadequately evaluated. McKenna^®
was unable to examine his cases postoperativelv
to prove the presence of sperm. Schuck operated
on ninety-seven of 200 and noted that the growth
of the operated organ was not improved.^® Wan-
gensteen^^ called attention to the fact that opera-
tion was incapable of completely restoring the
germinal epithelium to normal function. Such
restoration is possible in the experimental animal
whose testes are returned to a normal scrotal
position after having been temporarily resident in
the abdomen ; but this appears not to follow in
the human being.

Endocrine Therapy. — In this connection I
should like to call attention to the fact that the
use of A.P.L. postoperatively is frequently
recommended to improve the growth of the struc-
tures which have been restored to the normal
scrotal position. However, I have never seen
enlargement and have not been convinced by re-
ports in the literature that the size of the testicle
itself is ever influenced significantly by the ad-
ministration of anterior pituitary-like hormones.
If you recall that the action of anterior pituitary-
like substance is almost wholly luteinizing in the
female and interstitial cell stimulating in the
male, it becomes manifest that the prime results
to be obtained upon exhibition of this substance
in the male is the elaboration of testosterone and

the consequent development of the evidences of
testicular hormone effect such as the growth of
body hair, the change of voice, enlargement of
the prostate, enlargement of the seminal vesicles,
et cetera.

I have every reason to believe that testicles
are capable of developing an interstitial cell mass
without at the same time development of semini-
ferous tubules. It has been my good fortune to
study the case of a young man because of his
sterile union who showed every evidence of good
masculine development except for the presence
of two pea-sized testicles in a mid-scrotal posi-
tion. The semen was somewhat deficient in
quantity, measuring about 2 c.c. and not a single
sperm was visible in the specimen.

. Recommendations

I should like to make a recommendation based
on known physiological principles. I should like
to recommend that the follicle-stimulating hor-
mone as it is today available extracted from
pregnant mares’ serum* be used in cases of
cryptorchidism postoperatively with or without
the concomitant use of A.P.L. The so-called
follicle-stimulating hormone when exhibited in
the male is known to exert its effect on the
seminiferous tubules and the germinal epithelium.
I have no experience with this type of postopera-
tive treatment, having only discovered a suitable
case within the last few days, but I feel obligated
to call the theoretical considerations to your at-
tention inasmuch as the maintenance and restora-
tion of fertility are the prime objects of the
treatment of cryptorchidism rather than simply
to obtain a cosmetic effect.

Summary

The causes of cryptorchidism are not com-
pletely elucidated.

Most cases appear to depend on anomalous
conditions of the peritoneum covering the sper-
matic vessels and vas and the appearance of
fascial bands obstructing complete descent.

Hormone treatment should be tried during
the first years of puberty (nine to fourteen
years) as a means of differentiating cases with
mechanical obstruction, as an aid to surgery
and to effect descent in about 20 per cent of
the cases.

*The dose is unknown but might well be 10 units twice weekly
over a prolonged peuod.

110

CONGENITAL UMBILICAL HERNIA— NELSON AND FANDRICH

A.P.L. should be used in doses sufficient to
induce pubertal changes such as hair and genital
growth which will require doses up to 1000 to
1500 R.U. weekly for an average of two months.

If operation is done, it should be done within
the same age limits and should be followed by
hormonal treatment to insure the restoration of
the germinal epithelium without which any treat-
ment is to be considered a failure.

Bibliography

1. Bigler, J. A., Hardy, L. M., and Scott, H. J.: Cryptor-

chidism treated with gonadotropic principle. Am. Jour.
Dis. Child., 55:273, (Feb.) 1938. . , , j

2. Cabot, Hugh: The management of the incompletely de-

scended testis. South. Surgeon, 4:331, (Oct.) 1935.

3. Cone, R. E.: The management of cryptorchidism. Jour.
Urol., 42:240, (Aug.) 1939.

4. Creamer, A. J. : Evaluation of hormone therapy for un-

descended testes in man. Endocrin., 21:230, (Mar.) 1937.

5. Dorff, Geo. B., IV: The treatment with gonadotropic
hormones (anterior pituitary- like) of nonadipose boys show-
ing genital dystrophy. Jour. Fed., 10:517, (Apr.) 1937.

6. Engle, E. T. : The action of extracts of anterior pituitary
and of P. U. on the testes of immature rats and monkeys.
Endocrin., 16:506, (Sept. -Oct.) 1932.

7. Johnson, Wm. W. : Cryptorchidism. Jour. A.M.A., 113:25,
(July) 1939.

8. Kearns, W. M. : The clinical application of testosterone.
Jour. A.M.A., 112:2255, (June 3) 1939.

9. Kunstadter, R. H. : The treatment of hypogenitalism in the
male with the gonadotropic principle of pregnant mares’
serum. Endocrin., 25:661, (Nov.) 1939.

10. McKenna, C. M., and Ewert, E. : Management of undes-
cended testicle. Jour. A.M.A., 105:1172, (Oct. 12) 1935.

11. Moore, C. R. : The behavior of the testis in transplanta-

tion, experimental cryptorchidism, vasectomy, scrotal insula-
tion and heat application. Endocrin., 8:493, (July) 1924.

12. Nixon, N.: The undescended testicle. Am. Jour. Dis.

Child., 55:1037, (May) 1938.

13. Schuck, Franz: Cryptorchidism. New York State Jour.

Med., 38:1064, (Aug. 1) 1938.

14. Thompson, W. O., Bevan, A. D., Heckel, N. J., McCarthy,
E. R., and Thompson, P. K. : The treatment of undescended
testes with anterior pituitary-like substance. Endocrin, 21:
220, (Mar.) 1937.

15. Thompson, W. O. and Heckel, N. J. : Precocious sexual
development from an anterior pituitary-like principle. Jour.
A.M.A., 110:1813, (May 28) 1938.

16. Thompson, W. O., and Heckel, N. J. : Undescended testes.
Jour. A.M.A., 112:397, (Feb. 4) 1939.

17. Wangensteen, O. H.: The undescended testis. Annals

Surg., 102:875, (Nov.) 1935.

Michigan has been making big strides in developing
its maternal and child health program, according to
the latest reports to the Children’s Bureau.

Commenting on the census figures, the Bureau states
Michigan’s maternal death rate declined from fifty-two
in 1936 to thirty-six in 1937. In 1938 the rate was
thirty-seven, but the one point increase was not suf-
ficient to be statistically significant in view of the num-
ber of births involved, the Bureau points out. Michi-
gan’s 1938 rate was also held by three other states —
Indiana, New Jersey, and Vermont.

Michigan’s infant mortality rate in 1938 was forty-five
per 1,000 live births, a drop of three points compared
with 1937. One other state, Idaho, had the same rate
as Michigan, while seventeen states had lower rates.
The lowest state rate — thirty-six per 1,000 live births —
was established by Connecticut and Nebraska.

There are still too many avoidable deaths of mothers
and young babies in the United States, according to the
Children’s Bureau. Although the maternal and infant
mortality rates for the United States in 1938 were the
lowest on record, it is estimated that at least one out
of two maternal deaths, and one out of three deaths
of young babies can be prevented.

February, 1941

Congenital Umbilical Hernia

With Eventration

By Harry M. Nelson, M.D.
and

T. S. Fandrich, M.D.

Harry M. Nelson, M.D.

M.D., University of Michigan, 1920. Chief
Gynecologist and Senior Attending Obstetri-
cian, Woman’s Hospital. Assistant Professor
Obstetrics and Gynecology, Wayne University.

Director Tumor Clinic, Woman’s Hospital.

Fellow of the American College of Surgeons.

Member, Michigan State Medical Society.

T. S. Fandrich, M.D.

A.B., M.D., University of Michigan, 1935.

Junior Attending Obstetrician and Gynecolo-
gist, Woman’s Hospital. Member, Michigan
State Medical Society.

■ The NUMBER of cases of congenital umbilical
hernia with eventration reported in the litera-
ture are few enough to make each case interest-
ing. Most of the case reports are found in the
foreign literature, only a few being in
our own.

The case we are reporting is as follows :

Mrs. C. R., aged twenty-eight, para II. Last men-
strual period September 2, 1937, making estimated
date of confinement June 9, 1938. Previous pregnancy
March 25, 1936, at which time a normal 8 lb. 3 oz. full
term female was born. No complications or postpar-
tum morbidity were present.

Patient gave a normal menstrual history. Onset age
12, 28/7 type. Childhood diseases consisted of pertussis,
measles and mumps. No operations except tonsillectomy
and adenoidectomy.

This pregnancy was uneventful except for nausea
and vomiting during week before admission to hospital.
Onset of labor was exactly two weeks before expected
date. The patient entered the hospital in labor and de-
livered 4 hours and 12 minutes after onset. Blood
pressure on admission 90/50, pulse 96, temperature
98.8. Fetal heart was 140 on admission and rose to 158
one hour later. No analgesics or sedatives were given
patient during labor.

The baby was a 6-pound 4-ounce female, born spon-
taneously after a midline episiotomy. It cried vigorously
and required no resuscitation of any kind.

At the time of birth it was noted that approximately
14 inches of the ileum, cecum and ascending colon were
lying free, outside of the abdomen. There was no sign
of a hernial sac. The opening in the abdominal wall
was fully the size of a half dollar, and the umbilical
cord was attached to the left of this opening. As soon
as the baby was born, the intestines were wrapped in
warm saline sponges and within twenty minutes the
infant was taken to the operating room. By this time,
practically all of the intestines were outside of the

111

CONGENITAL UMBILICAL HERNIA— NELSON AND FANDRICH

abdominal cavity. This was thought due to the release
of intrauterine pressure.

Under drop ether anesthesia, the opening of the
abdominal cavity was extended above and below, and
after considerable difficulty, all of the intestines were

Fig. 1. Drawing of baby as it appeared immediate-
ly after birth, showing the umbilical cord to the
left lateral side of the openmg; the cecum, appendix
and small intestine.

placed back in the abdominal cavity. Through and
through silk sutures were used to close the abdominal
opening, after having excised the umbilical cord.

The baby lost weight during its first three days, going
down to 5 pounds 11 ounces. At the time of its dis-
change, on the twenty-fifth day, it weighed 6 pounds
12 ounces. The only abnormality in an uneventful con-
valescence was daily partial regurgitation of formula
and some vomiting, which had entirely disappeared by
the twelfth day. The baby was discharged on the
twenty-fifth postpartum day and has been in perfect
health since. At the present time (November 21, 1939),
the child is normal and active, weighing thirty-two
pounds and twenty-three inches tall.

It is obvious that this congenital defect is rare,
when it is estimated that it occurs only once in
5,000 deliveries.®

Embryological Factors

Stein and Gerber^® stated some of th^ embryo-
logical factors related to this subject as follows:
The primitive gut and ventral body wall are
formed primarily by a ventral bending and fus-
ing of the originally flat germ layers which rest
upon the yolk sac.

On each side, the splanchnopleure first curves

ventrally and fuses with the member of the oppo-
site side in the mid line, to form the gut. Shortly
thereafter, the somatopleure fuses in the same
manner in the ventral medial line to form the
body wall. It is apparent that a defective fusion
of the two sides of the somatopleure would re-
sult in a more or less extensive medial cleft. The
cleft may extend from neck to pelvis, associated
with a stillbirth, or may be limited to a small por-
tion of thorax or abdomen.

Further factors, given by other writers,®’^’®’^^
are listed as : Traction on the umbilical cord ; un-
due pressure in the abdominal region because of
faulty fetal position; inhibition of growth of the
abdominal wall ; a disturbed relationship between
growth of the abdominal cavity and its contents ;
and accidental bands of adhesions. There is no
evidence of familial tendency in this defect of
development.

Summary

1. Report of a case, interesting because of un-
eventful convalescence, probably because of early
surgery.

2. Presentation of a few points in embryologi-
cal development of this area, with a few etiolog-
ical possibilities, as mentioned by other authors.

References

1. Boydur, D. C. : Bull, et mem. Soc. d. Chir. de Paris,

28:464-465, (July 3) 1936,

2. Glass, Oscar: Massive umbilical hernia with enterocystoma

in a newborn. Amer. Jour. Obst. and Gynec., 29:748-749,
(_May) 1935.

3. Gordon, J. W. : Jour. Mich. State Med. Soc.. 31:533, 1932.

4. Herbert, A. F. : Amer. Jour. Obst. and Gynec., 15:86,

1938.

5. Jarcho, J. S. : Surg. Gynec. and Obst., 65:593, 1937.

6. Keith, A.: Brit. Med. Jour., 1:435, 1932.

7. Krumm, J. F. : Congenital hernia with eventration and

absence of sac. Amer. Jour. Obst. and Gvnec., 22:442-

443, (Sept.) 1931.

8. Lasserre, C., and Balard: Bordeaux Chir., 5:193-194,

(July 31) 1934.

9. Magendie, J., and Ponyanne, L. : Bordeaux Chir., 9:56-61,

(Jan.) 1938.

10. Massabuan, G., and Guibal, A.: Arch. d. malde I’app.

Digestif., 23:129-150, (Feb.) 1933.

11. Niebuhr, Dresch and Logan: Jour. A.M.A., 103:16, 1934.

12. Scio, A.: Riv. San. Siciliana, 21:595-597, (April 15) 1933.

13. Stein, J. L., and Gerber, A.: Congenital omphalocele:

A report of four cases. Amer. Jour. Ped., 14:89-91, (Jan.)

1939.

14. Thunig, L. A.: Arch. Surg., 33:1021-1045, (Dec.) 1936.

15. Vanverts, J., and Palliez, R. : Bull. Soc. d’ Obst. et de

Gynec., 21 :66-67, (Jan.) 1932.

Michigan has added to its maternal and child health
staff a consultant in pediatrics to work in organized
territory through the local health departments in de-
veloping this pediatric consultant service. He is to act
as consultant to local practitioners in pediatrics in rural
areas and wherever such consultant service is not other-
wise available. He also lectures to county and district
medical societies on the practice of pediatrics, talks
to lay groups on the care of children, and participates
in the state program of postgraduate education through
lectures in organized centers. He has recently com-
pleted a comprehensive study of all infant deaths in the
year 1939 in the city of Flint.

112

Tour. M.S.M.S.

FEMININE PSYCHOLOGY— SCHWARTZ

Feminine Psychology

With Emphasis on the Gynecological
and Obstetrical Phases

By Louis Adrian Schwartz, M.D.

Detroit, Michigan

Louis Adrian Schwartz, M.D.

BSc. in Medicine, University of Michigan,

1924. M.D., University of Michigan Medical

School, 1926. Examining Physician for Pro-
bate Court, County of Wayne from 1931.
Consulting Psychiatrist, North End Clinic, De-
troit, Mich. Consulting Neuropsychiatrist, Con-
sultation Bureau of the Detroit Commun-ty
Fund. Associate Physician at Harper Hospital,

Detroit. Consulting Psychiatrist at Woman's
Hospital, Detroit. Member of Michigan So-
ciety for Neurology and Psychiatry; Fellow of
the Psychiatric Association; Member of Ameri-
can Orthopsychiatric Association; Member of
the Detroit Psychoanalytic Society; Member
of Michigan State Medical Society; Member of
American Psychoanalytic Society.

■ The history of medicine is filled with re-
corded observations indicating that there are
definite connections between psychological and
physiological processes. Dr. Franz Alexander^
has pointed out, in his “Medical Value of Psy-
choanalysis,” that these connections were per-
ceived almost intuitively from general observa-
tion in the prescientific and prelaboratory pe-
riod,” when the physician “laid a much greater
stress on the psychological state of the patient
and attempted to explain disease not only as a
consequence of pathological changes in the differ-
ent organs but as a consequence of the conditions
of the patient’s life” ; that, with the growth of
scientific research and detailed empirical observa-
tions, the introduction of psychological factors
was naturally “resisted by the biologically ori-
entated physician, who was reminded of those
days, not long past, when medicine was a branch
of sorceiy and therapy a form of exorcism,” and
that “the invasion of medicine by psycholog}" is
felt by the majority to introduce an unknown
factor, incapable of tangible and scientific defi-
nition and approach.”

Somatic Effects of Psychogenic Disturbances

There has been abundant supportive evidence
showing that psychogenic disturbances of the or-
gans of the body, the functions of which are
regulated by the autonomic nervous system, can
result in definite anatomical and structural
changes. The connection of the cortex with the
visceral organs through the sympathetic and para-

sympathetic system is sufficiently well known, and
this connection implies that essentially ever}*
peripheral physiological process, in whatever part
of the body it takes place, can potentially be in-
fluenced by psychological factors. There is a
complicated interrelation between the autonomic
ganglia and the central nervous system, and all
visceral organs receive nerve fibers both from
central origin and from sympathetic ganglia
which lie outside of the central nervous system.
Therefore, the concept of the autonomic nervous
system is much more functional than anatomical,
because morphologically they are closely interre-
lated and the innervation of the inner organs is
always mixed.

The sexua.1 functions, in the broad sense,
probably represent the most instinctive phe-
nomena of organic life and, in the life of wom-
en, this function holds a most important place,
for upon it depends the phenomenon of mater-
nity. It is certain that, until recently, as far as
woman is concerned, any education which
touched upon her sexual life was essentially a
denial of the instinctual basis for sex, and that
many of the sexual disturbances which have
spoiled the lives of more than one woman
could have been avoided by rational education.

As Dr. Karl Menninger'* has pointed out, the
starting point for many gynecological manifesta-
tions on a functional basis is often to be found
in slight, quasi -physiological disturbances.
Sometimes it is a woman’s great anxiety for ma-
ternity which leads her to consult a g}’necologist,
or sometimes it is a sexual manifestation which
may form the starting point of errors of inter-
pretation, thereby turning the woman’s mind
towards the idea of some real affection of her
genital apparatus.

Relation to Inhibition

Research studies as to the psychological deter-
minants of somatic symptomatolog}' have made it
quite apparent that many symptoms can frequent-
ly be explained by the assumption of psychologi-
cal inhibition. In other words, a degenitalization
of the genitals, as it were, can take place. Nat-
urally, long-continued frigidity or vaginismus
could not exist without some corresponding struc-
tural changes, or at least atrophy, of the tissues
and glands, which is characteristic of any unused

February, 1941

113

FEMININE PSYCHOLOGY— SCHWARTZ

part of the body. That the emotional life has
some relationship to frigidity would appear to be
demonstrated by numerous reported cases in
which a reorganization of the psychic life results
in pregnancies ten to twenty years after mar-
riage.® Some gynecologists have gone so far as
to postulate details of the physiological mechan-
isms of this phenomenon. Sellheim, in 1925, as-
sumed that the emotional factors are reflected
in an over-action of the ovaries, resulting in pre-
mature maturation of the follicles, so that ova
are discharged which are not yet ready for fer-
tilization. He believed that, in some cases, this
could be cured by psychotherapy, in others by a
gradual reconciliation of the woman to her ster-
ility, and that this reconciliation served to de-
crease the pathological emotional stimulation of
the ovary and hence allowed it to discharge nor-
mal ova, thereby terminating the sterility. In
this connection, the conclusions of Benedek and
Rubenstein^ (based on independent observations
which were then correlated simultaneously) are
of interest :

1. The day-by-day study of vaginal smears and basal
body temperatures provided a useful and enlightening
method for analysis of gonad function of adult woman.

2. The psychoanalytic method could also be em-
ployed for a day-by-day study of the cycle of propa-
gative function on the psychological level.

3. The simultaneous use of the two methods pro-
vided clear correlations between the physiological and
psychological processes.

4. The investigation suggests that in the adult wom-
an, it was possible to relate instinctual drives to spe-
cific hormone functions of the ovaries.

5. Whenever the metabolic gradient, correlated with
the specific gonadal hormones, changes its direction or
slope, the psychological material shows a change in the
direction of the instinctual drive.

This was the first time that an accurate meth-
od has been provided, affording an approach to
a study of the biological foundations of the in-
stincts.

Frigidity. — To go back to the theme of frigid-
ity, some women vomit after every act of coitus.
Many patients stop vomiting during pregnancy
when, by suggestion, after an anesthetic, they are
merely told that the pregnancy has been termi-
nated. There are innumerable devices used by
patients to bring about self-punishment or to re-
ject the pregnancy by vomiting, or to develop
other sudden, inexplicable, severe symptoms. To

be pregnant is a great psychic trauma to some
women, and many difficulties developing coinci-
dentally are, in essence, protestations and the
wish to reject the child.

Pseudo Pregnancy. — There is also the so-
called nervous or phantom pregnancy — pseudo-
cyesis. Some women are haunted by the idea of
maternity because they either so greatly desire it
or fear it, and a curious group of phenomena can
be developed, simulating pregnancy, with the ex-
ception of uterine gravidity, even to its very last
symptom.

Menstrual Disturbances. — Coming to the uter-
us itself in its non-gravid form and functions,
we think, first, of all those disturbances of men-
struation which have been traced to a direct con-
nection with the unconscious repudiation of fem-
ininity. Of these, amenorrhea is the most logical
and dysmenorrhea probably the most frequent.
But not infrequently, menorrhagia, metrorrhagia
and even leukorrhea have also been identified as
psychologically predetermined, and by removal or
correction of the psychopathology, amelioration
of the symptom becomes easier. The rejection of
the female role, which is dependent on deep-lying
hostility, is directed outwardly against men and
inwardly against the feminine part of themselves
by reason of which some women feel so inferior.
There also arises a sense of guilt which is fo-
cused upon that part of the body where a repudi-
ation of femininity has been made concrete.
There is a wide variety of phenomena, ranging
from behavior reactions through functional aber-
rations to actual structural changes. All of them
may be visualized as representations in different
spheres of a profoundly influential drive, _the
subjective aspect of which is a wish to repudiate
femininity ; that this may appear in the form of
perverted symptoms has been known in some de-
gree since the hysterical syndrome was first rec-
ognized. Recent studies in the endocrines have
shown the presence of the products of the glands
of internal secretion of the opposite sex, in vary-
ing degrees, in each individual.

Psychological studies have also clearly
established, in some cases, the unconscious
wish of the little girl to be a boy, based on the
physical and social advantages accruing to the
male sex, and this unconscious wish to repudi-

114

Jour. M.S.M.S.

FEMINIXE PSYCHOLOGY— SCHWARTZ

ate her femininity has been found to have been
exaggerated later by the shock of the first
menstruation, by defloration, or fear of child-
birth. That the functional aberration which we
call hysteria may become structuralized into
various organic changes is at least a logical
hypothesis, but it is not yet proved.

Tt can be agreed certainly that any symptom
may be psychogenic, chemogenic or physiogenic,
and that any disease may be considered as a com-
bination of all three, but none can represent any
one of these factors alone. We attempt to inter-
pret the psychological aspect of these conditions
with the physics and chemistr}* with which we are
more familiar.

Puerperal Psychoses

Tn the past it has been common to describe
certain psychoses occurring at physiological
epochs and to give them the name of the epoch
during which they occurred, e.g., the “puerperal
psychoses” and the “lactational psychoses.” In-
fection and exhaustion are frequent causes oper-
ating at such periods to produce mental disturb-
ances. A large number of these psychoses are, in
reality of the infection-exhaustion t\q)e. Psycho-
genic factors are also of prime importance. A
depression during pregnancy may mean that the
wife is not in love with her husband and, there-
fore, does not want his child. It will be under-
stood, however, that the strains incident to preg-
nancy, parturition, the puerperium and lactation
may produce outbreaks of various psychoses, par-
ticularly dementia precox. There is no such thing
as a “puerperal psychosis” strictly speaking.
Mental disorder frequently occurs during the
puerperium but must be classified in accordance
with the symptoms it presents rather than the
time of onset. A patient may be too immature
to withstand the responsibility of motherhood.
Patients who have had a history of a psychotic
episode at parturition should be advised not to
have further children, especially where there is a
clear-cut psychotic episode with regressive symp-
toms, and where there is no evidence to show
that the condition is primarily a toxic or infec-
tious one. A histor}^ of fever with delirium, or
evidence of renal damage or circulator}' failure
usually rule out the toxic, infectious cases. We
have had occasion to see patients who have been
advised by physicians to marry and have a child

as a therapeutic measure to get over a previous
nervous breakdowm. We feel that this is unwise
advice as, by superimposing added emotional
strains upon an already overburdened personality,
one may precipitate a more lasting mental con-
dition.

Climacteric Changes

Among the most common and intractable psy-
chological problems with which the g}mecologist
must deal are the involutional depressions or the
beginning melancholia at the climacteric period.

In general, these conditions are found in a
rather characteristic type of woman. Usually,
these women have been somewhat indulged or
pampered, have loved the idea of being loved,
have found narcissistic satisfaction in being
wanted, and have basked in the affection be-
stowed upon them rather than in the fact that
they gave in love. This is true in general but
not necessarily so in every case. When such
women approach the menopause, they resent
the physical changes in their appearance, feel
they are not loved or wanted, develop ideas
that their husbands are unfaithful because
they are no longer as attractive as formerly, or
develop ideas of unworthiness and self-accu-
sation.

In many such cases, removal from the home
and placement in a sanitarium becomes a neces-
sity. A new environment with new associations
and different interests can be utilized. Theelin,
particularly in larger doses, has been found to be
of great value. The families of such patients
should be advised to be more tolerant, patient and
encouraging, and eveiy effort should be made to
safeguard the patient’s ego. A feeling of “be-
longing,” of making a contribution to family
life, is an important psychological device in im-
proving the mental attitude of such patients.
This is a psychological epoch in the life history
of a woman and should be dealt with sympathet-
ically by her family and in a patient, understand-
ing way by the physician.

Summary

In summary', the problem of feminine psychol-
ogy cannot be related to factors inherent, namely,
the anatomical, physiological, psychic character-
istics of women alone, but also must be consid-

Febru.^ry. 1941

115

CLINICO-PATHOLOGICAL CONFERENCE

ered as importantly conditioned by the culture
complex or social organization and the individual
psychology, through the experience of the woman
herself in terms of her early relationships and
training.

Some of the theories advanced may sound
fantastic, but it is suggested that they may be
only foreign to our usual thinking. If one
wishes to have more than a mere emotional
judgment, there is only one way scientifically
valid — a testing of the facts.

Repeated observations, case material, contrast-
ing attitudes on the part of the individuals from
the social, economic and cultural standpoints,
show the universality of these dynamic factors
which have been described. Such scientific ob-
servations as to the frequency of the types de-
scribed give the social factors relatively slight
value, while difficulties in personal development,
when repeated as traumatic events and as dis-
turbed relationships, can be seen as more signifi-
cant. Such emotional conflicts, which are ac-
companied by their physical counterparts, can
best be dealt with by the understanding physician
when the symptoms first present themselves.

References

1. Alexander, Franz: The medical value of psychoanalysis.

New York: W. W. Norton & Co., 1932.

2. Benedik, Therese, and Rubenstein, Boris B.: Correlations

between ovarian activity and psychodynamic processes: I.

The ovulative phase. Psvchosomatic Med., 1 :No. 2, (April)
1939.

3. Dejerine, J., and Gauckler, E. : The psychoneuroses and
their treatment by psychotherapy. Translated by Smith Ely
Jelliffe, M.D., New York, 1913.

4. Menninger, Karl: Somatic correlations with the unconscious
repudiation of femininity in women. Bull. Menninger
Clinic, (July) 1939.

"IF THIS BE TREASON . . ."

Is the American Medical Association a trust? Yes,
it is — a sacred “trust.” From its very beginning the
A.M.A. has considered the health of the American
people above all else. It led the fight against diploma
mills, and through its efforts medical education was
placed on its present high plane. The A.M.A. was
instrumental in raising the standards of hospitals so
that today American hospitals are the finest in the
world. It has striven continuously to give the Ameri-
can people the best quality of medical care that the
people of any great nation enjoy. But, because it does
not fall in line with all the schemes proposed for the
distribution of medical care, the A.M.A. must now be
purged.

We say, in the words of Patrick Henry, “If this be
treason, make the most of it !” — Milwaukee Medical
Times, reprinted in Illinois Medical Journal, January,
1941.

ClinicD-Pathological

Conference

Detroit Receiving Hospital
Thursday, December 5, 1940

S. T., a colored man, forty-six years of age, was ad-
mitted to the hospital on June 5, complaining of short-
ness of breath and swelling of the ankles of three
weeks’ duration, and hiccoughing of two weeks’ dura-
tion.

Present Illness. — The patient had felt as well as ever
(including a completely normal exercise tolerance) un-
til November of the preceding year, when he started
to notice generalized weakness and mild pains in his
knees without swelling or appreciable disability. Dur-
ing the winter he had several episodes of pain in his
finger tips which he attributed to frost-bite. About '
three weeks before admission his fatigue increased and
he became short of breath upon even mild exertion.
There was slight intermittent painless swelling of the
ankles which usually came on in the evening and dis-
appeared by the following morning. He went to a
private physician who took a blood test and told him
his blood was “bad.” He then gave the patient three
intravenous injections of a yellow medicine. About
two weeks prior to admission he started to hiccough
and continued to do so.

Past History. — General health good. Malaria in 1912.
Penile lesion at age of 17. Received no treatment until
1930 (age 36) when he was given an indeterminate
number of bip and arm injections. He had had occa-
sional treatments since. No history of rheumatic fever.
No previous severe illnesses or hospitalization.

Occupational History: Odd jobs. ^

Family History and Marital History : Not of contrib-
utory value.

Physical Exammation revealed a poorly nourished
though well-developed colored male lying flat in bed
and hiccoughing. Height 5'8", weight 119 pounds. Tem-
perature 99.8°, pulse 114, respirations 25. Eyes: pupils
were equal and regular, reacting normally to light and
upon accommodation. The ocular fundi showed normal
vessels and disks. There were no hemorrhages or ex-
udates. No icterus of the sclerse.' No petechiae. Ears
and nose ; negative. Mouth : mucous membranes were
pale but not otherwise remarkable. Neck: no venous
engorgement but marked carotid artery pulsation.
Trachea in midline. No tracheal tug. No cervical or
other lymphadenopathy. Lungs : normal resonance.
Medium crepitant rales at bases. Heart: apical impulse
palpable in the fifth interspace in the mid-clavicular
line. Systolic thrill in first right interspace in paraster-
nal line on deep expiration. No increase in supra-car-
diac dulness. Rough blowing systolic murmur in the
aortic area with a soft diastolic murmur heard also
in aortic area and transmitted downward along the
left border of the sternum and to the apex. At the
apex the first heart sound was slapping in quality.
Also at the apex there was a blowing systolic murmur,
and a rumbling murmur which persisted throughout
diastole without definite presystolic accentuation. Reg-
idar rhythm. Blood pressure: right arm 120/50; left
arm 11V40, abdomen: liver and spleen not palpable. l
No masses or tenderness. No ascites. Extremities: col-
lapsing radial pulse ; normal reflexes. No edema. No J
clubbing. Rectum and genitalia : negative.

Laboratory Studies on Admission. — Urinalysis: spe-
cific gravity 1.016, sugar 0. albumin 0. sediment neg-
ative. Blood : Hemoglobin 9.0 grams, RBC 2.98, index
0.9 WBC 4.000, neutrophiles 80 per cent, eosinophiles
2 per cent, lymphocytes 18 per cent, icterus index 5.5, ^

Tour. M.S.M.S.

116

CLINICO-PATHOLOGICAL CONFERENCE

blood urea 33 mg per cent. Kline and Kahn positive.
Subsequent laboratory tests : 6/22 — hemoglobin 9.0

grams. RBC 3.69, WBC 17,450, neutrophiles 88 per
cent, lymphocytes 12 per cent. Blood sulfathiazole
levels: 7/5 — 2.5 mg per cent; 7/8 — 5 mg per cent;
7/11 — 3.6 mg per cent; 7/15 — 2.9 mg per cent; 7/18 —
2.6 mg. percent. Numerous urinalyses showed variations
in specific gravity between 1.005 and 1.020, occasional
slight traces of albumin. The sediments were almost
always negative except for a few to 25 white blood cells
on three or four occasions. X-rays and electrocardio-
grams to be reported.

Clinical Course. — During his hospital stay the pa-
tient ran a swinging type of temperature varying be-
tween 99 and 103 degrees. Sulfathiazole therapy was
started on July 3, and there was a drop of the tempera-
ture to normal starting on July 4, and persisting to
July 10. In spite of continuance of sulfathiazole ther-
apy, the patient developed fever again ranging between
normal and 102°. Sulfathiazole therapy was stopped on
the twenty-first for a period of five days, and the fever
persisted. The pulse rate was consistently elevated
ranging between 80 and 130. During the period of nor-
mal temperature the average pulse rate decreased to
about 100 and then subsequently became more rapid
again. The respirations varied between 20 and 25 with
occasional rises to 30 and a terminal rise to 45. The
patient’s hiccoughs disappeared and then recurred on
several occasions without being very troublesome. He
gradually lost weight, became generally weaker and
expired on July 28 without developing signs or symp-
toms of localizing value.

Dr. Edward D. Spalding. — This is an interest-
ing case because while in a good many respects
the history and physical findings are quite
straightforward and point in one direction there
are one or two aspects which will bear consider-
able discussion. The history of this patient’s
illness does not contribute nearly as much as do
the physical findings and laboratory data and so
I shall comment upon it only briefly. The fact
that he was perfectly well until seven months pre-
ceding his hospital admission should be kept in
mind as being some evidence against a diagnosis
of chronic rheumatic heart disease. The episodes
of pain in his .finger tips which the patient at-
tributed to frost-bite are, in view of the other
findings, very suggestive of the lodging of emboli
in the fingertips which is commonly seen in bac-
terial endocarditis. I do not feel that the hic-
coughing is of any diagnostic significance in this
situation. In regard to the past history, the at-
tack of malaria does not impress me as being
connected in any way with his present illness.
The inadequacy of the anti-syphilitic treatment
greatly favors the possibility that a patient who
has syphilis will develop cardiovascular involve-
ment and is a point in favor of this as the basis
for this patient’s heart disease. The absence of
a history of rheumatic fever is not of much sig-
nificance since many patients with rheumatic
heart disease lack such a history. In the physical

examination the absence of petechiae is notew'or-
thy. The history of the episodes of pain in his
finger tips may be equivalent in importance and
thus counterbalance the former. The absence
of a tracheal tug is also significant but again its
presence would be much more significant since
it is always pathognomonic of an aneurysm of
the aortic arch. Unfortunately, it is frequently
absent in aneurysms of the aorta in general and
also in some aneurysms of the aortic arch. The
lack of engorgement of the cervical veins and the
normal area of supracardiac dulness are further
evidence against the presence of an aortic an-
eurysm, although the roentgenogram not infre-
quently shows an aneurysm when there are no
physical signs to indicate its presence. The pres-
ence of the rough systolic murmur in the aortic
area and the thrill in the first right interspace
bring up the possibility of either a rheumatic or
arteriosclerotic aortic stenosis or a roughening of
the aortic valve due to the presence of bacterial
vegetations. The lack of presystolic accentuation
of the apical diastolic murmur in the presence
of a regular rhythm is against the causation of
this murmur by a rheumatic mitral stenosis.

Therefore, we are probably dealing with
syphilitic aortic insufficiency and this finding
at the apex is probably an Austin-Flint mur-
mur. I have a good definition for two of these
atypical cardiac murmurs which so frequently
lead to confusion. The Austin-Flint murmur
may be defined as a diastolic murmur at the
apex of the heart occurring in an admitted case
of aortic insufficiency that leads one to sup-
pose that there may be a mitral stenosis; and
in the same way a Graham- Steele murmur
may be defined as a diastolic murmur at the
base of the heart in an admitted case of mitral
stenosis that leads one to suppose that there
may be an aortic insufficiency.

From the cardiac findings, therefore, we can
well explain the entire picture of a diagnosis
of syphilitic disease at the aortic orifice with-
out postulating involvement of the mitral
valve. However, I cannot definitely exclude
the possibility of rheumatic aortic stenosis.

One of the significant laboratory findings is
the absence of red blood cells in the urine.
Again this negative finding should not be
given too much weight. I doubt whether the
electrocardiograms will be particularly help-

February, 1941

117

CLINICO-PATHOLOGICAL CONFERENCE

ful in this case. From considerable experience
in Clinico-pathological Conferences, one can
make several inferences from some of the lab-
oratory data which are present and from some
of the laboratory data which are absent. The
sulfathiazole levels combined with the clinical
picture indicate to me that this man almost
certainly had bacterial endocarditis since I
can think of no other reason for which sul-
fathiazole would have been given. The men-
tion of blood cultures has undoubtedly been
purposely omitted.

In considering the course of this patient in
the hospital, the fall in temperature which oc-
curred on the day after the administration of
sulfathiazole was started, is probably signifi-
cant, in spite of the fact that the fever re-
curred while sulfathiazole was still being giv-
en, although at a slightly lower level. While
sulfathiazole usually temporarily sterilizes the
blood stream, the organisms remain buried in
the heart valves where they are not suscepti-
ble to attack from the drug. Therefore, while
the fever and bacteremia may be controlled in
part by the sulfathiazole most types of bac-
terial infections persist.

I have recently seen a case with acute bac-
terial endocarditis in which the infecting or-
ganism was the micrococcus sicca, an unusual
organism belonging to the group of gram neg-
ative diplococci such as, the gonococcus and
meningococcus. This organism, like the others
in its group, is apparently much more sus-
ceptible to the sulfonamide drugs and this
patient was apparently cured although it is
too soon to know whether this will be perma-
nent. The organism in the present case is
probably streptococcus viridans, a notoriously
bad actor as far as response to treatment is
concerned. In preferring the diagnosis of sub-
acute bacterial endocarditis superimposed up-
on a syphilitic lesion of the aortic valve, I
realize that there are considerable odds against
this being the case since this complication is
comparatively rarely seen. Chronic rheumatic
heart disease with aortic stenosis and insuffi-
ciency, mitral stenosis and insufficiency and a
superimposed subaciite bacterial endocarditis
must be mentioned as a very possible alter-
native diagnosis.

Dr. Saul Roscnzweig. — I should like to em-
phasize the fact that this patient had a tem-
perature of 99.8° on admission to the hospital.
Usually patients with valvular heart disease
exist on a lower pyrexial plane than other pa-
tients and, therefore, the presence of fever
immediately arouses the suspicion of some
complication.

The x-rays may aid in the differential diagno-
sis of the cause of aortic insufficiency by showing
a change in the left border of the heart indica-
tive of enlargement of the left auricle when
there is rheumatic heart disease with co-existing
mitral stenosis. Also in such a case the electro-
cardiograms may show a tendency toward right
axis deviation or heightened notched P waves
which would not be seen in syphilitic aortic in-
sufficiency. In this case I favor the diagnosis of
subacute bacterial endocarditis with underlying
chronic rheumatic heart disease with aortic ste-
nosis and insufficiency and miteral stenosis and
insufficiency for these reasons : ( 1 ) The ac-

centuated first sound at the apex, (2) the loud
aortic systolic murmur and thrill, and (3) the
comparative rarity of syphilitic heart disease as
the basis for bacterial endocarditis. In my opin-
ion the absence of a presystolic accentuation of
the diastolic apical murmurs is not inconsistent
with the presence of mitral stenosis even though
the cardiac rhythm is regular.

Further Studies

(Presented following the clinical discussion)
Fluoroscopic and roentgenographic examination of
the chest showed moderate congestion in both lung
fields. The costophrenic sinuses were clear. The heart
was normal in size, shape and position. The cardiac
pulsations were of the rocking-beam type. There was
some widening of the aorta.

The electrocardiogram showed a normal axis and
normal sinus rhythm. The P waves were upright, of
normal size and contour. The T waves were of low
voltage in the three standard leads and of normal
voltage in the precordial lead. Electrocardiographic in-
terpretation : “Probable myocardial damage.”

The blood cultures were repeatedly positive for
streptococcus viridans and varied as indicated in the
accompanied illustration.

Resume of the Pathological Findings
Final Diagnosis:

1. Subacute bacterial endocarditis involving both
mitral and aortic valves, chiefly the former, su-
perimposed upon chronic rheumatic valvulitis.

2. Syphilitic aortitis and aortic valvulitis.

The heart weighed 430 grams constituting Grade I
cardiac hypertrophy. There was no pericarditis and
mural thrombi were absent. There was widening of
the commissures of the ao’"tic valve and thickening of
the aortic valve leaflets. The posterior leaflet was ul-
cerated and at this point there were attached small
bacterial vegetations. The mitral valves were thick-

JouR. M.S.M.S.

118

CLINICO-PATHOLOGICAL CONFERENCE

ened and fibrous and attached to the right cusp there
was a large, soft, greenish-yellow vegetation. The cir-
cumference of the mitral valve was 11 cm. and that
of the aortic, 7 cm. Microscopically there was nodular
fibrosis of the mitral valve constituting evidence of
preexisting rheumatic infection. This was not sat-
isfactorily demonstrated in sections of the aortic valve.

Dr. Paul H. Noth. — The response of this pa-
tient’s disease to sulfathiazole therapy is illus-
trated in the accompanying figure. The tempera-
ture chart is a composite one for varying num-
bers of days as recorded on the topmost line.

S.T. X-8547 BL, H. AGE 46 ADM. 6/5/40 DIED 7/28/40 AUTOPSY DIAGNOSIS - U. I.

Aortic insufficiency was due chiefly to syphilitic valvu-
litis and this was contributed to by the presence of bac-
terial vegetations. Autopsy cultures were positive for
streptococcus mitior (viridans).

The left pleural cavity contained 800 c.c. and the
right 500 c.c. of fluid, the specific gravity of which was
1.015. The right lung weighed 720 grams and the left
800 grams. Both lungs were diffusely dark and firm.
Microscopically there was a typical picture of chronic
pulmonary congestion, the outstanding features being
the presence of large numbers of heart failure cells in
the alveoli and thickening of the alveolar walls due to
connective tissue h^'perplasia.

The liver weighed 1770 grams. The cut surface was
mottled yellow and red, the lobular definitions being
abnormally conspicuous. In the liver sections there was
a wide anemic zone about each central vein composed
of atrophic pale-staining liver cells. The pallor of this
zone was due to edema superimposed upon passive hy-
peremia, the edema fluid having collected between the
sinusoidal endothelium and liver rods, producing termi-
nal narrowing of the sinusoids.

Excluding congenital valve defects, it is apparent
that subacute bacterial endocarditis is usualh*, if not
always, superimposed upon preexisting rheumatic valvu-
litis, even though the presence of rheumatic infection
cannot always be demonstrated. The presence of sub-
acute bacterial endocarditis involving the aortic valve
apparently superimposed upon syphilitic aortic valvu-
litis should probably lead to the suspicion of associated
rheumatic valvulitis even though the evidence of rheu-
matic infection is largely obliterated by the syphilitic
lesion.

After sulfathiazole therapy was started the fever
decreased and then disappeared with an accom-
panying sterilization of the blood stream. How-
ever, in spite of continued sulfathiazole admin-
istration the temperature rose. Temporary with-
drawal of the drug to exclude the possibility of
its producing the fever was followed by a return
to positive of the blood cultures. The drop in
hemoglobin and red blood cell count occurred
before sulfathiazole was started and, therefore,
was not caused by it. Four other patients suffer-
ing from subacute bacterial endocarditis due to
streptococcus viridans have been treated at Re-
ceiving Hospital with sulfathiazole. Three of
these patients received no benefit from the drug
as indicated by the continuance of fever and
positive blood cultures. The fever of one patient
subsided and his blood culture became negative
for slightly more than one month, after which
the fever returned and the blood cultures became
positive in spite of continued administration of
the drug.

Febru.^ry. 1941

119

Medical Rehabilitation
of

Rejected DraRees

☆

Rehabilitation of draftees with remedial defects —
for industry and for the man — is the plan of the
Michigan State Medical Society.

A study of the causes which have forced the Se-
lective Service to reject young men for military work
will first be made by the State Society. The reports
the Society receives would indicate that medical care
has been available to these youths but that most of
the defects can be attributed to heredity or environ-
ment or in some instances to carelessness, disinterest
and neglect. The State Society will investigate whether
those in the relief, W.P.A. and depressed economic
groups were given opportunities to obtain needed med-
ical services.

After the study of causes has been completed, a
program of rehabilitation will be outlined by the
Michigan State Medical Society. This is planned
primarily to aid the youth in having his remedial de-
fects eliminated so that he may become more val-
uable to himself and to the community by usability
in industry.

jpfedulent

aae

☆

President, Michigan State Medical Society.

120

Jour. M.S.M.S.

-X EDITORIAL x-

REUEF FOR THE DOCTOR

■ Negotiations, which have been in a rather

nebulous state for several years and have be-
come a very practical issue for some months,
have culminated in a most constructive economic
advance for the physicians of Michigan.

Mr. William J. Burns, Executive Secretary of
the Michigan State Medical Society, made the
initial contacts and a committee of The Council
with Mr. Burns has finally secured a voluntary
agreement with the representatives of the insur-
ance companies active in Michigan, which should
be most welcome to every practitioner (See page
123). It should definitely be realized that the
fullest cooperation was forthcoming from the
representatives of the associations of insurance
companies both from the “old line,” and the
“mutual” companies as well as the “independent”
companies of Michigan. Their enthusiastic aid
was most acceptable and appreciated.

One of the headaches of the practice of
medicine has been the fact that the attending
physician to an automobile accident victim has
too frequently been unable to collect for his
services. The same situation also has been a
vital problem for hospital management. Now
there will be some relief from an unpleasant
situation !

The gist of the agreement is that the patient,
who has been injured in an automobile accident
and for whom an insurance company is to be
financially responsible, will sign an agreement
giving the insurance company the right to make
separate checks covering charges for services to
the hospital and physician. There should be but
little difficulty in getting this assignment from
the patient while the memory of the service ren-
dered is still fresh in his mind. The one agree-
ment will cover both the hospital and the physi-
cian. The insurance companies have promised
to assist the physicians in every possible way in
getting these signatures and in the subsequent
legal procedures.

Of course, there are a great many of these ac-
cident cases (not covered by any insurance)
which must still be cared for as charity but at
least the physician will know that if an insurance

company is liable for the care of his patient, the
money for his services probably will not be used
by the “grateful” patient to buy a new car or a
fur coat instead of paying the bills for services
which saved him from pain, suffering, or even
from death.

In Wisconsin a similar agreement has been
in existence for two years. In Massachusetts
there is a separate agreement for the physicians
and for the hospitals.

If this works out as satisfactorily in Michigan
as it has in Wisconsin and Massachusetts, physi-
cians of Michigan, as did The Council, may well
applaud the work of this committee which com-
pleted this welcome agreement.

BACK TO THE SEVENTEENTH CENTURY
BY ORDER OF THE SUPREME COURT

■ The Medical Practice Act under which we
are operating says that anyone who wishes to
practice “medicine, surgery and midwifery” must
prove his qualifications and ability to safely per-
form these services.

In a recent decision, the Supreme Court of the
State of Michigan has held that since the law
does not say “and/or midwifery,” one who prac-
tices midwifery alone is not legally required to
qualify to perform this service and is under no
supervision.

For some reason not known to the unjudicial
mind this ruling does not apply to “surgery” even
though the wording is the same. From a medical
point of view it is impossible to intelligently di-
vide these three parts.

Since the beginning of organized medicine in
Michigan the medical profession has urged the
utmost care in the supervision of qualifications
to practice medicine, surgery and midwifery
realizing that in order to continue with the pre-
vention of maternal mortality this trinity must
be indivisible. The knowledge of a belated lay
interest in this search for the best care for the
prospective mother makes this legal ruling seem
to hark back to the dark days of the seventeenth
century. Perhaps the newly gained social and po-

February, 1941

121

EDITORIAL

litical enthusiasm added to the pleas of our own
profession may bring forth from the present leg-
islature even more rigid supervision over the
practice of medicine than exists at present.

Wm. J. Burns Roy Herbert Holmes

COUNCIL ELECTIONS

■ At the annual meeting of The Council held
January 11 and 12 at Dearborn, Michigan,
Treasurer Wm. A. Hyland, M.D., Secretary L.
Fernald Foster, M.D., and Editor Roy Herbert
Holmes, M.D., were rejected to their respective
offices.

The annual reports of these officers are printed
in the Annual Proceedings of the Council else-
where in this issue and portray the extent of ac-
tivity of the Michigan State Medical Society.

The Council also unanimously re-appointed
Mr. William J. Burns as Executive Secretary for
another year. Perhaps the most significant testi-
monial to his activity is the increase in member-
ship of the society from thirty-five hundred to
forty-five hundred during his five years as Exec-
utive Secretary for the Michigan State Medical
Society.

CORRECTION

In a letter commenting on the editorial, “E>on’t Nurse
Your Babies,” in The Journal for June, 1940, Doctor-
E. F. Daily, chief of the Maternal Health and Child
Welfare Division of the Department of Labor, states
that the Department of Labor does not have any su-
pervision over the State Unemployment Compensation
Commission. He says that the Social Security Com-
mission sets minimum standards for the State Un-
employment Commission.

How an Attorney General Thinks We Should Practice

122

Jour. M.S.M.S.

MICHIGAN HOSPITALS AND MEDICAL PAYMENTS

(Accident Cases — Agreement of Insurance Companies, State Medical Society

and Hospital Associations)

The Michigan State Medical Society has con-
ferred with hospital authorities and repre-
sentatives of insurance companies to effect an
agreement whereby hospitals and physicians may
be more definitely assured of payment for their
services to those individuals who are injured in
accidents and who, because of their injuries, are
indemnified by an insurance carrier.

Such an agreement has been reached. It has
been carefully considered and incorporated in it
are the best thoughts of those concerned.

Ev'ery physician member of the Michigan
State Medical Society and every hospital super-
intendent is urged to read with exceeding care
the information which is contained hereafter, as
it is only through a thorough understanding of
the provisions contained in the agreement that
it can he effectively used.

The annual toll of those injured or killed as
a result of automobile accidents has served to
place an increased financial burden upon the
hospital and the physician.

Seldom does the lay public appreciate the costs
to the institutions and profession in the services
rendered. Bandages, dressings, staff nurses, food,
medicine, splints and the like are all items of
expense.

There are 152 registered hospitals in this state.
Their construction and equipment involve the
investment of millions of dollars and their avail-
ability to a community is a matter of necessity.
They serve a community purpose ; they protect
and promote the health and well-being of the
people. Their charitable contributions are enor-
mous but are so strained that imposition must be
avoided wherever possible.

Inability to collect even for the initial outlay
of materials constitutes a source of great finan-

cial strain and is becoming of such magnitude
as to involve the welfare of the community served
as well as of the people assisted. Insurance com-
panies are willing and anxious to afford to the
fullest measure possible that cooperation which
will offer the maximum degree of relief to both
professional groups and protection to the com-
mun ty at large.

It is appreciated that large numbers of such
cases are indemnified in whole or in part from
insurance protection. In countless numbers,
however, the funds are dissipated by the pa-
tient, and the hospital and physician remain un-
paid, despite the fact that the settlement was pre-
dicted, often in its entirety, upon the expenses
incurred.

Insurance companies are appreciative of the
problem. It is to their interest as financial con-
cerns (and to the interests of their policyholders
and claimants as well) to take all feasible steps
to assist in the solution of that problem.

Prompt medical and hospital care is recog-
nized as preventive of serious consequences in
the greater number of cases. Early disposition
of claims is conducive to the health and we 1-
being of the patient, and is attainable through the
prompt cooperation of patient, doctor and hos-
pital.

Knowing that this problem existed, it was
recognized that a satisfactory^ arrangement should

♦Medical endorsements are divided into two kinds : (a) in-
cludes only the guest in the automobile and not the named
insured; (b) this type covers the named insured and the
occupants. Both endorsements are sold only when a liability
policy exists, and are endorsements to the general type of
automobile liability policy sold. The medical endorsement
covers expense for medical, surgical, dental, graduate nurse,
hospital and ambulance services, and, in the event of death
resulting from such injury, the reasonable funeral expense,
all incurred within one year from the date of the accident.

February, 1941

123

MICHIGAN HOSPITALS AND MEDICAL PAYMENTS

be made for the payment of hospital and medical
costs in those instances in which the injured party
received remuneration from the insurance car-
rier.

It should be understood from the outset that
this agreement is not a panacea for the phys-
ician’s or hospital’s financial problems in accident
cases. It covers only those cases in which pay-
ment is to be made to the injured party by the
insurance carrier, whether hospitalized or not, or
where the insurance carriers, in accordance with
their standard clause, pay expenses incurred by
the insured for such immediate medical and
surgical relief to others as shall be imperative at
the time of the accident, or where indemnity is
made under a medical endorsement.*

The Michigan Hospitals and Medical Payment
Plan agreement has been approved by the Amer-
ican Mutual Alliance, the Association of Cas-
ualty and Surety Executives, a group of inde-
pendent Michigan Insurance Carriers, the Michi-
gan State Medical Society, and the Michigan
Hospital Association.

There is established a conference committee
to adjudicate disputes that may arise under its
operation and to further cooperation to the end
that if any hospital, physician or insurance com-
pany feels that it has a grievance, such grievance
may be placed before it for mediation and arbi-
tration.

The Committee is composed of one represen-
tative from the Michigan Hospital Association,
one representative of the Michigan State Medical
Society and two representatives of insurance
companies.

The Conference Committee established under
the agreement will elect a chairman and a per-
manent secretary. The secretary will receive any
complaints from hospitals, physicians or insur-
ance companies, in writing, and will place the
complaints before the conference committee
which has been established. The secretary will
also act as a clearing house from which forms
(1), (2) and (3) may be obtained. The cost of

the forms in pads of 100 will be 50 cents. Cash
must accompany all orders for blanks.

The effective date of operation of the Michi-
gan Hospitals and Medical Payments Plan is
March 1, 1941.

It is emphasized that the fundamental confi-
dental relationship between the physician or hos-
pital and patient shall be maintained under the
agreement as it has in the past. Information
relative to the injuries sustained by a patient as
a result of an accident should be supplied to the
insurance company only when the physician or
hospital has on file the signed form which gives
the hospital or physician the privilege to so in-
form the insurance company. Specifically the
agreement provides “Insofar as possible the
insurance company representatives will cooperate
with the hospital and the physician in securing
such orders.”

As soon as the payment form (number one or
two) has been signed by the patient, the original
copy of this form should be sent to the insurance
company, or companies, affected. Failure to ob-
tain payment from the insurance company, due
to the fact that it has no liability in the case, does
not preclude the physician or hospital from ob-
taining payment from the patient. Likewise, if
the settlement for the injuries is not sufficient to
cover the hospital and medical care, the physician
and hospital may obtain the unpaid balance di-
rect from the patient.

The agreement which is made a part of this
bulletin should be thoroughly discussed in hospi-
tal staff meetings and the procedure to be fol-
lowed by the individual hospitals should be clear-
ly understood. It is strongly recommended that
the approval of the physician be obtained in all
instances before the forms are mailed or given
to the insurance companies by the hospital. Space
has been provided on the forms for the signa-
ture of the attending physician.

The conference committee extends to all par-
ties interested an invitation to place before the
committee any suggestions, criticisms or com-
plaints. If there is any question relative to the

124

Tour. M.S.M.S.

MICHIGAN HOSPITALS AND MEDICAL PAYMENTS

operation of this plan, it may be submitted to
the secretary of the conference committee.

The agreement, as approved by the ^Michigan
Hospital Association, the ^Michigan State Medical
Societ}', the American ^lutual Alliance, the As-
sociation of Casualty and Surety Executives, and
the independent group of ^lichigan companies, is
printed in its entirety in the following para-
graphs :

Michigan Hospitals and Medical
Payments Plan

Doctors and hospitals have in the past ex-
perienced difficulties in securing the payment
of charges from patients who have collected
damages from persons causing their injuries
despite the fact that in such cases a part of the
patient’s financial recovery actually was based
on hospital, medical, and surgical expense.

Those principles are therefore enunciated in
an effort to protect in so far as possible the in-
terests of hospitals, medical and allied profes-
sions, insurance companies, the community
and general public:

1. Except as the patient or his lawful rep-
resentative may otherwise direct, the funda-
mental confidential relationship between the
physician or hospital and patient shall be
maintained. It is recognized that in order
properly to submit a claim not only the early
details of the injuries suffered must be dis-
closed, but also the expense which the injured
party has incurred. In event of lawsuit or set-
tlement, disclosure of this information is un-
avoidable, but the election so to disclose is that
of the injured patient, and is his to be exer-
cised. Therefore when so authorized by the
patient, the physician and hospital will supply
to the interested insurance company or com-
panies complete information concerning the
injuries and prognosis.

2. The obligation incurred by the injured
party for necessary medical, surgical and hos-
pital care is one primarily owing to either the
physician or hospital. Payments by the insur-

ance company by way of indemnifying the pa-
tient therefor should be applied toward the liq-
uidation of such obligation to the extent such
funds are available, and to assist therein, the
insurance companies will recognize orders on
proper forms for reasonable charges upon such
funds which ultimately may become payable
to the patient or his personal representative.
In so far as possible, the insurance company
representatives will cooperate with the hospi-
tal and the physician in securing such orders.
Where the payment is insufficient to afford
satisfaction to all parties concerned, the insur-
ance company will endeavor to pay physicians’
and hospital bills on an equitable basis.

3. In order that the insurance companies
may furnish the fullest cooperation (and for
the hospital’s or physician’s own proper pro-
tection) the physician and hospital shall notify
insurance companies promptly of any claim
upon which an order has been or may be
issued.

4. In event of settlement with a patient who
refuses or has failed to sign an order, the in-
surance company will endeavor to carry out
the principles set forth in paragraph two and
when this cannot be done will notify the hospi-
tal and physician before settlement or if such
advance notice is not possible, then as soon
thereafter as can be done.

5. The company shall pay any expense in-
curred by the insured, in the event of bodily
injury, for such immediate medical and surgi-
cal relief to others as shall be imperative at
the time of accident.

6. A Conference Committee of four, consist-
ing of two insurance company representatives,
and two representing the medical and hospital
interests will be created to mediate disputes
and to further cooperation.

X.B. Address orders for forms, inquiries,
suggestions, or complaints for the attention of
Conference Committee either to L. Fernald Fos-
ter, M.D., 2020 Olds Tozi'er, Lansing, Michigan;
or to Robert Greve, 1313 E. Ann Street, Ann
A rh or, Mich iga n .

February, 1941

125

MICHIGAN HOSPITALS AND MEDICAL PAYMENTS

Form 1

Order for Payment

Medical, Surgical and Hospital Bill

19. . .

To;

(name of insurance company)

(Address)

If and when any settlement is made by you on account of my claim against

(name of person(s) causing injury)
arising out of injuries sustained by me on or about

sideration of my being received for treatment by

, and in con-

(da:e)

(name of physician or hospital)

you are hereby directed to pay the full amount of my bills for treatment, services and care to

(name of physician or hospital) (address)

I understand this order does not relieve me of my obligations to pay such bill if not paid by your j
company, or any balance due after payment by your cor?pany. i

Witness :

Signed :

(signature of injured person)

i

(address)

This form has been approved by the American Mutual Alliance, the Association of Casualty and Surety Exec-
utives, a group of Michigan Insurance Carriers, the Michigan Hospital Association, and the Alichigan State
Medical Society.

126

JouK. M.S.M.S.

MICHIGAN HOSPITALS AND MEDICAL PAYMENTS

Form 2

Order for Payment

Medical, Surgical and Hospital Bill
for Minor or Incompetent

19...

To;

(name of insurance company)

(address)

If and when any settlement is made by you on account of claims against

(name of person (s) causing injury)

arising out of injuries sustained by

(name of minor or incompetent)

on or about , and in consideration of such party being received for

(date)

treatment by

(name of physician or hospital)

you are hereby directed to pay the full amount of the bills for treatment, services and care to

(name of physician or hospital)

(address)

I understand this order does not relieve the undersigned of any obligation to pay such bill if
not paid by your company, or any balance due after payment by your company.

(father or guardian)

Witness :

(mother)

This form has been approved by the American Mutual Alliance, the Association of Casualty and Surety Exec-
utives, a group of Michigan Insurance Carriers, the Michigan Hospital Association, and the Michigan State
Aledical Society.

T^ep.ruary. 1941

127

MICHIGAN HOSPITALS AND MEDICAL PAYMENTS

Form 3

Information Authorization

,19...

To: .;

' (name of physician or hospital)

(address)

You are hereby authorized to give

(name of insurance carrier)

insuring the person or persons against whom (I) (We) have a claim arising out of injuries sus-
tained by

(name of injured party)

(or by me) on or about , or any representative of such insurance company,

(date)

a complete report of injuries and disabilities arising therefrom, hospital record and any other re-
quested information pertaining to such injuries and disabilities, and copies thereof, and to permit
it to examine the original records in your presenceif they should desire so to do.

Witness :

(patient, or if minor, signatures of father,
and mother, or guardian)

Approved :

This form has been approved by the American Alutual Alliance, the Association of Casualty and Surety Exec-
utives, a group of Michigan Insurance Carriers, the Michigan Hospital Association, and the ^Michigan State
Medical Society.

128

Jour. M.S.M.S.

MICHIGAN MEDICAL SERVICE

The steady growth of Michigan Medical Serv-
ice during its first year of operation is but an
indication of the continuous benefits possible
for both subscribers and doctors. During this
period, more than 7,500 patients will have been
enabled to obtain needed medical services while
more than 1,500 doctors will have received in
excess of $240,000 for their services to these
patients.

No one can yet measure the full effect of the
medical service plan in making the services of
doctors readily available or in preventing un-
remunerated services or bad debts for doctors.
Certainly the prospects are most hopeful.
Through Michigan Medical Service, the med-
ical profession has an agency that can combat
the medical economic problems which have be-
seiged doctors during the past ten years.

Improvements from Experience

The experiences gained in the actual oper-
ation of Michigan Medical Service during the
first year afford a real basis on which to build
improvements for the future. Many commit-
tees representing the various fields of medical
practice — committees of the Michigan Derma-
tological Association, the Michigan Branch of
the American Urological Society, the Mich-
igan Association of Roentgenologists, the Detroit
Roentgen and Ray Society, the Detroit Ophthal-
mological Society, the Michigan Association of
Obstetricians and Gynecologists, and the Mich-
igan Pediatric Society — have been called on by
the Medical Advisory Committee to give expert
counsel in regard to prevailing medical practices
and to formulate definite procedures under Mich-
igan Medical Service.

It is only through such close professional su-
pervision that the functions of the medical serv-
ice plan can be satisfactory.

Again, each doctor of medicine who has ren-
dered services for subscribers to Michigan Med-
ical Service can make the most important con-
tribution toward the successful administration
of the medical service plan by sending his sug-
gestions, comments, or criticisms to the Medical
Advisory Committee of Michigan Medical Serv-
ice, Washington Boulevard Building, Detroit.
So long as the Medical Advisory Committee is

MICHIGAN MEDICAL SERVICE
REGISTRATION
HONOR ROLL

(As of January 10, 1941)
100 Per Cent

Barry

Mason

90 to 99 Per Cent

Calhoun

Menominee

Monroe

Newaygo

Tuscola

80 to 89 Per Cent

Allegan

Bay-Arenac-Iosco-Gladwin

Chippewa-Mackinac

Clinton

Delta-Schoolcraft

Dickinson-Iron

Gogebic

Gratiot-Isabella-Clare

Hillsdale

Ingham

Kent

Lenawee

Mecosta-Osceola

Midland

Oceana

O.M.C.O.R.O.

Ontonagon
Ottawa
Saginaw
St. Joseph

75 to 79 Per Cent

Branch

Eaton

Houghton-Baraga-Keweenaw

Lapeer

Muskegon

Northern Michigan

Wexford-Kalkaska-Missaukee

notified of situations which can be improved,
progress can be made.

Know Your Michigan Medical Service

It is becoming more and more important for
every doctor to know the full provisions of the
Medical Service Plan and the Surgical Benefit
Plan of Michigan Medical Service.

MEDICAL SERVICE PLAN : Patients who
identify themselves as subscribers to the Med-
ical Service Plan of Michigan Medical Service

FEBRUi\RY, 1941

129

MICHIGAN ^lEDICAL SERVICE

will have a Michigan Medical Service Identifica-
tion Card which carries the designating Number
2, indicating that the subscriber is entitled to
both medical and surgical services of doctors
of medicine in the home and office as well as in
the hospital — including consultation services,
x-ray, laboratory, and anesthesia services. Ob-
stetrical services are not included until after
the patient has completed twelve months of mem-
bership.

Under the Medical Service Plan, services
necessary to establish a diagnosis only (no treat-
ment) are provided for tuberculosis, venereal
diseases, and mental disorders. For cancer and
malignant growths, benefits can be provided only
for the services necessary to establish a diag-
nosis and for the initial operative or radiologic
treatment.

Medical Services for alcoholism, drug addic-
tion, self-inflicted injuries, or for Workmen’s
Compensation cases are not benefits under Mich-
igan Medical Service. Likewise, benefits can
not be paid under Michigan Medical Service for
drugs, materials, appliances or supplies. The pa-
tient is responsible for all services, drugs, ap-
pliances or supplies which are not provided for
under Michigan Medical Service.

A recent liberalization of the Medical Service
Plan is the inclusion of benefits for the surgical
treatment of appendicitis and hernia whether or
not the subscriber has had attacks previous to
the date of his Certificate.

SURGICAL BENEFIT PLAN: Subscribers
to the Surgical Benefit Plan may be identified
by the designating Number 3 on the Identification
Card which indicates that the subscriber is en-
titled to surgical and x-ray services only when
a bed patient in the hospital. Obstetrical care
in the hospital after twelve months of membership
is also provided.

The Surgical Benefit Plan is a low-cost, par-
tial-service program and provides only for surg-
ical services when performed in the hospital.
Such services include the operative and cutting
procedures for the treatment of diseases and in-
juries and for the treatment of fractures and dis-
locations. Strictly medical or diagnostic services
in the hospital or surgical care in the home or
office are not included as benefits under the
Surgical Benefit Plan.

The x-ray benefits include diagnostic x-ray
services not to exceed $15.00 during the subscrip-
tion year for each person enrolled in the plan.
Before benefits are payable for x-rays under the
Surgical Benefit Plan, the subscriber must be a
bed-patient in a hospital. However, as an extra
benefit, payments will be made for diagnostic
x-rays of a surgical condition taken in the office,
if the patient has a surgical condition which im- |
mediately thereafter requires hospitalization. t

}

Initial and Monthly Reports

Be sure to send an Initial Service Report for t
each patient for whom benefits are to be paid by ‘
Michigan Medical Service. By completing this
short form carefully, it is possible to verify that
the patient is in good standing and eligible for
services. The exact spelling of the subscriber’s
name and the certificate number should be copied
from the subscriber’s Identification Card or Cer-
tificate. Each blank in this form should be filled
in with the proper information. If there is some
reason why the subscriber is not entitled to bene-
fits under Michigan Medical Service, a notice
will be sent by return mail. Unless the doctor •
is so notified, he will know that the subscriber
is eligible for benefits.

As soon as the services are completed, but in
no event later than the end of each month, a
Monthly Service Report should be sent to the
Medical Advisory Board for payment. This re-
port is an itemized statement of the services
rendered and should include an indication of
each service rendered in order that the proper
payment can be authorized.

Weekly Payments to Doctors

During the second year of operation, it will
be the endeavor of the Medical Advisory Board
to have payments made weekly to doctors. This
will be possible if the doctor sends in his report
promptly and gives in full the information re-
quested. Delay in payment of Monthly Service
Reports could be avoided if the doctor’s office as-
sistant would take the few minutes necessary to
give all the pertinent information requested in
the Monthly Service Report.

Michigan Medical Service opened its doors
one year ago — February 1, 1940!

130

Jour. M.S.M.S.

MEDICAL PREPAREDNESS IN MICHIGAN

The enactment of the Selective Training and
Service Law of 1940 called upon the medical
profession of each state to make a very great
contribution to national defense. The physicians
were asked to voluntarily make all the physical
examinations of men selected for military service
under the law.

The preliminary work for this program was
ver)^ nicely accomplished by the Michigan State
Medical Society when it formed a committee on
Medical Preparedness following the lead of the
American Medical Society. Under the able and
enthusiastic leadership of Burton R. Corbus,
M.D., past president of the Michigan State Med-
ical Society, the State Medical Preparedness
Committee quickly completed the formation of
a Medical Preparedness Committee in each Coun-
ty Society. This pioneer endeavor of the State
Society proved of inestimable value later.

The next operation was to organize a medical
department in Selective Service Headquarters
for Michigan to inform, assist and supervise
the doctors in executing the physical exami-
nation program. Using the facilities of the Mich-

igan State Medical Society, the State Medical
Preparedness Committee and the constituent
County Committees, the State Board of Registra-
tion in Medicine and the Michigan State Health
Department, this volunteer organization of Mich-
igan physicians was perfected with very little
difficulty. Approximately one quarter of the
physicians of Michigan are devoting a portion
of their time to Selective Service. Of a total
of 984 doctors of medicine, 705 are serving as
Examiners for 192 Local Boards, 260 members
of 19 Medical Advisory Boards, and 19 phy-
sicians on the 19 Appeal Boards.

The fact that hundreds of Michigan phy-
sicians so willingly cooperated in the venture
speaks well for the medical profession in Mich-
igan. The medical program is one of the most
important portions in the Selective Service Sys-
tem. It is apparent from the reaction of the
profession in Michigan that the doctors intend
to do their part with distinction.

Lt. Col. Harold A. Furlong, M.D.

State Medical Officer, Mich. Selective Service.

REMISSION OF DUES OF MEMBERS IN SERVICE

The Council of the Michigan State Medical Society, upon authority of the House of
Delegates, has ruled that active members of the Society with 1940 dues paid, who are serving
their country away from home in the armed forces of the United States, will be relieved of
paying 1941 dues, if recommended by the County Medical Society.

The Secretary of the County Medical Society shall fill out and return to the State
Society, 2020 Olds Tower, Lansing, the following form for each of the members in his
society whose membership is to be continued on the above basis. For the Secretary’s con-
venience, a number of these forms will be sent to him by the State Society;

“This is to certify that a member of the

(name of member)

County Medical Society, was called into active

service in the United States on 19....,

(branch of service) (date)

and is now on duty at

(name of post and location)

and for that reason is entitled to remission of 1941 dues in the Michigan State Medical

Society, in conformance with official action taken by The Council of the Michigan State

Medical Society on November 10, 1940.

(Name of Secretary) (County Medical Society)

The above does not apply to former members of the Michigan State Medical Society who
were not members in good standing in 1940; but it does apply to physicians completing
their medical education during 1940 or 1941 who are accepted as members of the county
medical society during 1941 and who are inducted into active militaiy* service in 1941.

February, 1941

131

MICHIGAN PROGRAM FOR GRADUATES IN MEDICINE

Cooperating Agencies

Michigan State Medical Society
University of Michigan Medical School
Wayne University College of Medicine
Michigan Department of Health

Courses Ann Arbor and Detroit

Allergy

Anatomy

Diseases of the Blood and Blood-forming Organs

Diseases of the Cardiovascular System

Diseases of the Genito-Urinary Tract

Electrocardiographic Diagnosis

Gastroenterology

Gynecology and Obstetrics

Laboratory Technic

Nutritional and Endocrine Problems

Ophthalmology and Otolaryngology

Pathology: Special Pathology of Neoplasms

Pathology of the Female Genito-Urinary Organs

Special Pathology of the Eye

Special Pathology of the Ear, Nose, and Throat

Pediatrics

Proctology

Roentgenology

Summer Session Courses

All Dates Inclusive
May 12-16

February 12-May 28
(Wednesdays)

May 12, 13 and 14
May 19-23
*

*

April 28, 29 and 30

June 30-August 8
!March 3-6
April 17-23
June 30-July 11
July 14-25
July 28- August 8
August 11-22

April 14-19

June 30-August 8 and 22

Extramural Postgraduate Course

March 2-1 — April 18

Ann Arbor

Battle Creek-Kalamazoo
Flint

Grand Rapids
Lansing-Jackson

Mt. Clemens
Saginaw

Traverse City-Manistee-Cadillac-Petoskey

For further information, address;

Department of Postgraduate Medicine
1313 Ann Street
Ann Arbor, Michigan

■*Dates to be announced later.

132

Jour. M.S.M.S.

1

X- YOU AND YOUR BUSINESS X-

NATIONAL CONFERENCE ON
MEDICAL SERVICE

The following five topics encompass most of
the economic thinking of the medical leaders of
the countr}' :

Medical preparedness

Voluntary group medical care programs
I Postgraduate plans of state medical societies
Aledical legislative problems
iMedical care for Social Security clients

These basic subjects will be presented in the
form of symposia at the National Conference on
Medical Service in Chicago on Sunday, February
16. The fifteenth annual meeting of the Confer-
ence will be held at the Palmer House. All Mich-
igan physicians, particularly those who are inter-
ested in medical economics or in any one of this
year’s subjects, are cordially invited to attend
I the Conference. There are no dues or registra-
i tion fees. The Conference marks an annual get-
: together of the best medical-economic minds of
I the country.

! MICfflGAN'S INTANGIBLE TAX

The following is a hypothetical example of a
j report on intangibles based on Michigan’s new
I intangible tax law ;

Unpaid accounts receivable (as of

9/30/40) $10,000.00

Less unpaid accounts payable 1,000.00

$ 9,000.00

Bank deposits : Commercial Acct. 1,(XX).00

Savings Acct 4,000.(X)

$ 5,000.00

Less exemption 3,000.(X)

2,000.00

Stocks and bonds (non-income

producing) 5,000.00

Amount taxable $16,000.(X)

Tax at .001 (1/10 of 1 per cent assuming
the above items are non-income producing) .001

Amount of tax $16.00

Less statutory exemption... 7.00

Intangible tax payable $9.00

If any of the above properties are income
producing, the maximum tax on that portion of
the property is .003 of the value.

Life insurance policies are not taxable. More-
over, if two people, such as husband and wife,
own a bank account jointly, each is considered to
own one-half of the account and each is entitled
to an exemption of $3,000 (unless there is evi-
dence to prove that the account is actually owned
by one of the two persons).

For detailed information and a copy of the
booklet on Michigan’s Intangible Tax Law, write
Joseph H. Creighton, ^Manager, Intangible Tax
Division, State Tax Commission, Lansing.

NOT A PRIVILEGED COMMUNICATION

“At a hearing in a personal injury case under
the Workmen’s Compensation Act, the plaintiff
called a physician to explain the nature of his
injur}^ The defendant thereupon called two phy-
sicians who had attended the plaintiff before the
accident to show that the plaintiff’s trouble was
chronic and of long standing. The latter testi-
mony was objected to by plaintiff’s counsel as
privileged. Held, that under the Michigan statute
the calling of one doctor by the defendant waives
his privilege as regards all who can testify re-
garding the condition in dispute.” Lacount v.
Van Platen-Fo3? Co., 243 Mich. 557, 220 N.W.
697 (1928).

MSMS DUES NOT RAISED

Dues of the Michigan State Medical Society
have not been raised but remain at $12.00 per
annum. While the Council was authorized by
the House of Delegates to levy’ an assessment of
$5.00 per member to cover emergencies, financial
matters were so well arranged during the past
year that no direct assessment or increase in dues
was required. Dues are now payable to secre-
taries of county medical societies. Include your
county society dues with the $12.00 dues of your
State Society.

The State Society Convention
September 17, 18, 19, 1941
GRAND RAPIDS, MICHIGAN

Febru.^ry, 1941

133

MID-WINTER MEETING OF THE COUNCIL
January 11 and 12, 1941

FIRST SESSION

1. Roll Call. — The meeting was called to order by

Chairman A. S. Brunk, M.D. in the Dearborn Inn,
Dearborn, Michigan, 9:30 a.m., January 11, 1941. Those
present were Drs. Brunk, Wm. E. Bar stow, Otto O.
Beck, Howard H. Cummings, T. E. DeGurse, Wilfrid
Haughey, Roy Herbert Holmes, W. H. Huron, A. H.
Miller, Vernor M. Moore, Ray S. Morrish, Rey C. Per-
kins, Philip A. Riley, E. E. Sladek, C. E. Umphrey ;
also President Paul R. Urmston, President-elect Henry
R. Carstens ; Secretary L. Fernald Poster, Treasurer
Wm. A. Hyland, Executive Secretary Wm. J. Burns.
Absent on account of illness : Drs. R. J. Hubbell and

O. D. Stryker.

2. Minutes. — The minutes of the Executive Commit-
tee meetings, including December 19, 1940, were ap-
proved as published, on motion of Drs. DeGurse-Cum-
mings. Carried unanimously.

3. The Secretary’s Annual Report was read by Dr.
Poster, as follows :

SECRETARY’S ANNUAL REPORT— 1940

I herewith submit the report of the Secretary for
1940

The year 1940 marked another year of sustained
effort in the execution of the many activities of or-
ganized medicine in Michigan. The established projects
were continued and new endeavors initiated by THE
COUNCIL, its Executive Committee and the various
committees of the Society.

Membership

The total paid membership for 1940 was 4,478 (plus
forty-three Emeritus and Honorary Members), with
net dues of $46,174.02 accruing to the Society. The
number of physicians with unpaid dues at the end of
1940 was sixty-three. The membership tabulation for
the years of 1939 and 1940 showing net gains and losses,
unpaid dues and deaths as follows :

1939 1940 Gain Unpaid Deaths

4,383 4,478 95 63 77

The present membership of 4,521, when compared
with a potential membership of the eligible physicians
in the State of 4,700, indicates that the saturation point
is rapidly being approached and that future yearly in-
creases in membership will be small.

MEMBERSHIP RECORD— 1940

^ t/5

« .S S- rt

O rt - 4;

1940 o ^ Q

24-1--
18 2---
12 2---
75 2 - 4 -

64 4 - 2 -

23 1 - - 1

120-3-3
14 _ 1 - 2

23 - - - 1

11----
27 2 ---

22-3--
32-4-2

178 - 15 2 3

24 - 1 - -

41 1 _ 1 .

37 - 1 1 2

26 1 - - 1

44-2--
28-2-‘-

143-2-3
46 - 4 1 1

94 - 1 1 2

115 3 - 3 1

Kent

234

244

_

10

6

6

Lapeer

16

15

1

1

Lenawee

44

43

1

_

Livingston

21

21

_

_

1

Luce

10

11

—

1

Macomb

39

43

_

4

_

1

Manistee

16

16

_

_

_

Marquette-A!ger

40

43

_

3

1

1

Mason

9

10

1

_

Mecosta-Osceola

16

16

_

_

Medical Society of North Central

Counties

23

22

1

--

2

Menominee

14

12

2

_

_

_

Midland

15

16

_

1

_

Monroe

35

35

_

2

1

Muskegon

79

80

_

1

2

Newaygo

13

13

_

_

Northern Michigan

33

37

_

4

2

2

Oakland

136

143

_

7

3

2

Oceana

11

12

_

1

Ontonagon

8

8

„

Ottawa

32

34

2

_

_

Saginaw

102

102

1

4

Shiawassee

31

29

2

_

1

1

St. Clair

55

52

3

_

1

St. Joseph

23

25

2

_

Tuscola

32

31

1

_

_

1

Van Buren

27

30

3

1

1

Washtenaw

174

173

1

3

3

Wayne

1,855

1,899

_

44

26

26

W'exford-Missaukee

21

22

-

1

-

4,383

4,478

30

125

63

77

4,383

30

95

95

Emeritus and Honorarv

Members

43

Paid Members

,478

Total

,521

Deaths During 1940

We regretfully record the deaths of the following
seventy-seven members during 1940 :

Branch County — A. G. Holbrook, M.D., Coldwater.

Calhoun County — Nils O. Byland, M.D., Battle Creek; Walter
F. Martin, M.D., Battle Creek; Albert W. Nelson, M.D., Battle
Creek, Stuart Pritchard, M.D., Battle Creek.

Cass County — C. M. Harmon, M.D., Cassopolis; John H.
Jones, M.D., Dowagiac.

Chippewa-Mackinac — J. A. Reese, M.D., DeTour.

Eaton County — James B. Bradley, M.D., Eaton Rapids; C.
A. Lown, M.])., Grand Ledge.

Genesee County — B. W. Malfroid, M.D., Flint; Herman G.
Rosenblum, M.D., Flint; A. S. Wheelock, M.D., Flint.

Gratiot-Isabella-Clare — Ralph E. Dawson, M.D., Blanchard;
C. D. Pullen, M.D., Mt. Pleasant.

Hillsdale County — William H. Ditmars, M.D., Jonesville.
Ingham County — Spencer D. Guy, M.D., Lansing; C. M.
Watson, M.D., Lansing; W. G. Wight, M.D., Lansing.
lonia-Montcalm — F. A. Hargrave, M.D., Palo.

Jackson County — John W. Page, M.D., Jackson; John C.
Smith, M.D., Jackson.

Kaiamasoo County — Edward Ames, M.D., Kalamazoo.

Kent County — T. P. Bishop, M.D., Grand Rapids; Willard
Burleson, M.D., Grand Rapids; John F. Cardwell, M.D., Grand
Rapids; C. D. Mulder, M.D., Spring Lake; Richard R. Smith,
M.D., Grand Rapids; Frank A. Votey, M.D., Grand Rapids.
Livingston County — Charles E. Skinner, M.D., Howell.
Macomb County — Reginald P. Humphreys, M.D., New Haven.
Marquette-Alger County — J. D. Crane, M.D., Ishpeming.
Medical Society of North Central Counties — Ruey O. Ford.,
M.D., Gaylord; F. W. Lee, M.D., Fairview.

Monroe County — A. W. Karch, M.D., Monroe.

Muskegon County — R. G. Cavanagh, M.D., Muskegon; S. J.
Drummond, M.D., Casnovia.

Northern Michigan Counties — Robert B. Armstrong, M.D.,
Charlevoix; J. G. MacGregor, M.D., Boyne City.

Oakland County — J. S. Morrison, M.D., Royal Oak; W. W.
Wiers, M.D., Royal Oak.

Ottawa County — ^Milan Coburn, M.D., Coopersville; John G.
Huizinga, M.D., Holland.

Saginaw County — Paul Kahn, M.D., Frankenmuth; Arthur
E. Leitch, M.D., Saginaw; Emil P. W. Richter, M.D., Saginaw.
Shiawassee County — G. B. Wade. M.D., Laingsburg.

Tuscola County — J. E. Handy, M.D., Caro.

Van Buren County — Chester A. Wilkinson, M.D., Kendall.
Washtenaw County — D. M. Cowie, M.D., Ann Arbor; Theron
S. Langford, M.D., Ann Arbor; Coral Adelbert Lilly, M.D.,
Ann Arbor.

Wayne County — J. M. Berris, M.D., Detroit; Josephus M.
Burgess, M.D., Northville; Paul W. Butz, M.D.', Plymouth;

Tour. M.S.M.S.

Allegan 23

Alpena-Alcona-Presque Isle .... 20

Barry 14

Bay-Arenac-Iosco-Gladwin 77

Berrien 68

Branch 24

Calhoun 117

Cass 13

Chippewa-Mackinac 23

Clinton 11

Delta-Schoolcraft 29

Dickinson-Iron 19

Eaton 28

Genesee 163

Gogebic 23

Grand T’-aver^e-T eelanau-Benzie . . 42

Gratiot-Isabella-Clare 36

Hillsdale 27

Houghton-Baraga-Keweenaw 42

Huron-Sanilac 26

Ingham 141

lonia-Montcalm 42

Jackson 93

Kalamazoo 118

134

MID-WINTER MEETING OE THE COUNCIL

Manley D. Caughey, M.D., Detroit; A. N. Collins, M.D., De-
troit; L. Irving Condit, M.D., Detroit; A. J. D’Alleva, M.D.,
Detroit; John B. Dibble, M.D., Detroit; William A. Evans,
M.D., Detroit; Thos. W. Ferguson, M.D., Detroit; Douglas

L. Gordon, M.D., Detroit; Samuel F. Haverstock, M.D., De-
troit; H. W. Hewitt, M.D., Detroit; E. C. Hoff, M.D., Detrojt;
Arthur G. Hubbard, M.D., Detroit; Jacob Levitt, M.D., Detroit;
Walter H. MacCracken, M.D., Detroit; R. D. MacKenzie, M.D.,
Detroit: Wilson Randolph, M.D., Detroit; Bruno J. Sawicki,

M. D., Detroit; Roy S. Smith, M.D., Detroit; Theodore H. Smith,
M.D., Detroit; G. W. Stockwell, M.D., Detroit; Prosper D.
White, M.D., Detroit; H. Wellington Yates, M.D., Detroit; L. L.
Zimmer, M.D., Detroit.

Financial Status

The fiscal ^ear closed December 21, 19-K), and the
statement of our certified accountants, Ernst & Ernst,
shows the financial condition of the Society on that
date. The following facts are noted :

The fiscal year of the State Medical Society closed
December 21," 1940. Our certified accountants, Ernst &
Ernst, have audited the books of the Society and have
furnished an analysis of our financial situation.- Their
report reveals the following facts.

The assets of the Society are given as $39,214.40
as compared with $43,399.91 of a year ago. The smaller
assets are due chiefly to allocation of $6,000 (market
value) of securities to the Trustee of Medical De-
fense Fund. The net worth is $37,788.63 as compared
with $24,224.35 last year, or a gain of $13,564.28.

There is a strong possibility that a part or all of
the money advanced to Michigan Medical Service for
organizational and working capital in the amount of
$17,544.45 may be repaid during the coming year. The
net worth of the Society will be enlianced to the extent
that this is done.

The income from dues was $52,770 as compared with
$51,518 in 1939, a gain of $1,252. Interest received
totaled $829.18, a gain of $66.12 over last j’ear. The
total income was given as $50,070.52 as compared with
$46,750.95 the previous 3^ear. These figures are found
bj^ deducting $6,595.98 allocated to the Journ.-\l and
adding the income from the Jourx.\l of $2,740.96, plus
interest received and miscellaneous income. The ex-
penses of the Society' totaled $36,125.24 divided as fol-
lows : The administrative and general $19,909.71, SocieW
activities $10,696.89, committee expense $5,518.64. The
expenses were $9,593.51 under the budget estimate.

The security portfolio, as a whole, has not been
changed. Securities having a total market value of
$6,000 were transferred to Dr. Wm. A. H3'land, Trustee
for the Medical Defense Fund. Some bonds showed
a total decrease in quoted market value of $637.50.
Other bonds showed an appreciation in market value
of $211.25. The U. S. Savings bonds showed apprecia-
tion due to interest accrual of $176.00. The old stock
held b3' the Societ3' decreased in market value $43.50.
The bonds of the Hyland Trustee account showed ap-
preciation of $172.75 and depreciation of $148.75 for
a net depreciation of $23.75. The combined net decrease
of all securities held in the State Medical Societ3' and
the Trustee accounts was $317.50.

The medico-legal defense fund account was closed
the previous 3'ear (1939) b3' the allocation on Jan-
uary 13, 1940, of securities worth $6,000 to Dr. Wm. A.
Hyland, Trustee. A separate audit of Trustee H3’land’s
account was made by Ernst & Ernst. It revealed re-
ceipts of $1,603.75 from the sale of securities, $387.50
interest received from securities and $75.00 repa3’ment
by members of M.S.M.S. of legal fees advanced b3* the
Trustee. This makes total receipts of $2,066.25. Dis-
bursements were for legal fees, $1,640.43 and premium
on Trustee’s bond, $12.50, totalling $1,652.93. The pres-
ent bonds in Trustee Hyland’s portfolio have a market
value of $4,341.25 which, with cash on hand of $413.32,
makes a total value of this account of $4,754.57.

To sum up — Income was higher b3' $1,252, expenses
were higher b3’’ $1,349 and were less than the budget
estimates b3’ $3,026.36. The increase and net worth
of the Society for the year was $13,564.28. The

February, 1941

Journal, while being subsidized from members’ dues
"by $6,595.98, showed a profit of $2,740.96, an increase
in profit over the budget estimate of $584.71. If it had
not been subsidized it would have resulted in a loss
of $3,855.02. The securit3^ accounts showed a loss in
market value of $317.50.

From the above figures it will be noted that the
Society was operated well within the budget require-
ments so that it faces the coming year in better
financial condition than a year ago. The anticipated
loss of income due to war activit3’ in the next few
3’ears can probably be met by the substantial saving
effected this 3-ear,

The 1940 Annual Meeting

An all-time high in attendance Avas established at the
19-10 Session in Detroit. There was a total registra-
tion of 2,561.

The General Session t3'pe of scientific program was
continued and was heartily endorsed 63* both the essa3'-
ists and members.

A lack of available facilities precluded the possibility
of a scientific exhibit at the 1940 meeting.

No expense was spared in bringing to Michigan an
outstanding arra3’ of out-of-state speakers, and ever3'
possible provision was made to make the convention
attractive. Despite the great expense incurred in main-
taining the high standard of the ^lichigan meeting,
a substantial profit again accrued to the Society as a
result of the large and well-developed technical exhibit.
The registrants at the convention showed their apprecia-
tion to the technical exhibitors by being very generous
in their attention to this group.

County Secretary Conferences

Three Count3' Secretary Conferences were held dur-
ing the year. One in Lansing in Januar3% one in Me-
nominee for the Societies of the Upper Peninsula in
Juh-, 1940, and one in Detroit on the occasion of the
Annual Meeting in September, 19-40.

The Januar3’^ Conference Avas unique in that one of
its sessions AAas held jointh’ Avith the Count3' Health
Directors of Michigan. A similar t3’pe of conference
is planned for 1941. Such an arrangement brings to-
gether tAvo im.portant groups, provides for an exchange
of vieAA-points and helps to better correlate health pro-
grams.

Committees

Time and space do not permit a detailed account
of committee activit3*, but 1946 marked a high point
in committee endeaA’’or. The deA^elopment of a PreA-en-
tive ^ledicine Committee by bringing together the chair-
men of all health committees has added much to the
efficienc3- of committee actu'ities and has been respon-
sible for better committee correlation.

To the alread3' large group of committees AA'as added
the J^Iedical Preparedness Committee and Conference
Committee on Prelicensure Medical Education. The
Preparedness Committee, working closeU AA'ith a similar
committee of the A.i^l.A., has and Avill continue to haA-e
much Avork to do.

I

Society Activities

During the 3-ear just closed, the 55th Count3- Society-
Charter Avas granted. This AA-as accorded the phy-
sicians of Huron Count3’ and marked the beginning
of the “Huron Count3^ !NIedical Societ3^”

As an innoAation in 1940, The Council approA-ed the
idea of holding “Councilor District” meetings. These
replace the meetings knoAA-n as “State Society Nights.”
Up to this time a district meeting has been held in
practically- each of the 16 Councilor Districts. In 1941
it is hoped that such meetings can be so correlated
that they AA-ill folloAv closely after the Annual Meeting
and thei'eby serve to stimulate the component units to

135

^[ID-WINTER MEETING OF THE COUNCIL

I

action on their programs and projects early in their
fiscal year.

During 1940 your two Secretaries contacted practi-
cally all of the 55 county units. On most occasions
they were accompanied by some members of The
Council.

It is gratifying to report that most of the Societies
are well organized and are manifesting a keen inter-
est in both the scientific and sociologic phases of medi-
cal practice.

Meetings are held regularly in most societies and
attention is properly divided between scientific discus-
sions and those -of an economic and political character.

As a result of a recommendation by The Council,
the House of Delegates in 1940 decided to continue
memberships without the collection of dues of all phy-
sicians called to Active Military Service. This splen-
did gesture has been followed by many county socie-
ties as well.

During 1940 twelve Secretary’s Letters were issued,
nine to Secretaries of County Societies and three to
all members of the Michigan State Medical Society.

Michigan Medical Service

While Michigan Medical Service has been operating
since March, 1940, as a separate organization, mention
should be made of the fact that very strenuous de-
mands have been made upon the time and energies of
this Council, its Executive Committee, the Officers
and Administrative personnel in the conduct of the
affairs of Michigan Medical Service. These individuals
have been most generous in this connection.

Your Secretary cannot express too sincerely and
earnestly to this Council his appreciation of its fine
cooperation and encouragement during the past year.
Much commendation is due the committees for their
splendid spirit and untiring efforts in the successful
execution of many difficult tasks.

To Mr. Burns, executive secretary, and the execu-
tive office personnel, too much appreciation for their
untiring efforts cannot be expressed.

Mr. Burns has been at all times most cooperative
and helpful, and has been a continual source of in-
spiration and aid. To all those who have aided so
generously in the discharge of the duties of this office,
your Secretary is truly grateful.

Respectfully submitted,

L. Fernald Foster, AI.D., Secretary.

The report zvith recommendation re dnes remission
was referred to the County Societies Committee.

by the Michigan State Medical Society, market value
as of December 21, 1940, is $22,811.25.

Total funds in my possession as Treasurer of }ilS
^IS, including bonds at quoted market prices $22,811.25
and cash in Michigan National Bank $707.59, total
$23,518.84.

Respectfully submitted,

Wm. a. Hyland, M.D.,
Treasurer

Report of Trustee Fund of Michigan State Medical
Society as of December 21, 1940
On January 13, 1940, the Michigan State Medical
Society delivered to Dr. William A. Hyland, Trustee,
the following bonds to hold as Trustee replacing the
former medical-legal fund, their approximate value
being $6,000.

Two New England Gas and Electric Company Bonds
Two Southern Pacific Railroad Company Bonds
Two Grand Rapids Affiliated Bonds
Two New York Central Railroad Bonds
One Consolidated Oil Corporation Bond
On April 1, 1940, the Trustee account sold one Con-
solidated Oil Company Bond to obtain money for cur-
rent medical-legal bills.

On August 1, 1940, the Trustee account sold one
New York Central Railroad Bond for current medical-
legal bills.

Total received from sale of Bonds to

Michigan State Medical Society $1,603.75

Interest received on Securities 387.50

Repayment to Trustee Fund by member
legal fees advanced 75.00 $2,066.25

Paid Legal fees amounting to 1,640.43

Paid Premium on Trustee’s Bond 12.50

1,652.93

Cash on Hand December 21, 1940 $413.32

Total amount of bonds turn over to Trustee
by Michigan State Medical Society quoted
at market prices of December 20, 1939. .$6,000.00
Interest on bonds 387.50

Deductions :

Legal fees paid 1,565.43

Premium paid on Trustee’s bond 12.50

Loss on sale of bonds to M.S.M.S 31.25

Reduction of carrying amount of secur-
ities held in trust December 21, 1940,
to quote market prices 23.75

1,632.93

Balance in Trust Fund December 21, 1940.. 4.754.57
On deposit at Michigan National Bank 413.32

Total market value of bonds in Trustee Fund 4,341.25

4. The Treasurer’s Report and the Trustee’s Report
were presented by Dr. Hyland as follows :

Total value of Trustee Fund $4,754.57

Wm. a. Hyland, M.D., Treastircr

TREASURER’S REPORT— 1940

As treasurer of the Michigan State Medical Society,
I wish to submit the following report for the year
1940.

As required by the by-laws of the Michigan State
Medical Society, the usual indemnity bond was filed
with the Secretary of the Michigan State Medical So-
ciety.

On April 15, 1940, the $1,000 Kresge Foudation bond
was called at $1,040.00. It was decided by the Bond
Committee to trade the Kresge Bond in the General
Account for the Consolidated Oil Bond in the Trustee
Account, in order to obtain cash for current Trustee
Account bills without selling any of the Trustee Port-
folio.

On August 1, 1940, the General Fund purchased the
New York Central Railroad Bond from the Trustee
Fund.

The present value of the bonds and securities held

These reports were referred to the Finance Com-
mittee.

5. The Editor’s Annual Report was presented by Dr.
Holmes, as follows :

EDITOR’S ANNUAL REPORT

The selection of scientific articles for The Journ.\l
has been based primarily upon the needs and desires
of the general practitioner who represents the ke}-
majority of the Michigan State Medical Society mem-
bership. Emphasis has been placed, therefore, upon short
practical articles of a not-too-highly specialized nature
and with most of the attention directed toward diag-
nosis and treatment of those conditions which are of
importance to the man in private practice. The belief
that this policy has been acceptable to this large portion
of our membership, is enhanced by the fact that no
adverse criticism has come to the Editor’s attention.

136

Jour. M.S.M.S.

MID-WINTER MEETING OF THE COUNCIL

During 1940. The Journal has published eighty-
I seven scientific articles averaging three and one-half
! pages in length. Of this number all were of a general
; nature : There were forty-three pertaining especially
■ to internal medicine; twelve to eye, ear, nose and
throat; nine to gynecology; six to surgery; five to
obstetrics ; three to orthopedics ; three to pediatrics ;
j three to economics ; two to proctology ; and one to
: urology. 'Of these papers, forty-nine were written by
members of the Michigan State Medical Society; and
thirty-eight were by out-of-state medical leaders, the
original papers having been given at a state or county
medical society meeting in Michigan. No other sources
of scientific papers were used.

The Editor has attempted to stimulate the use of
cuts, charts, et cetera, which aids considerably in im-
pressing the reader. Every attempt has been made to
keep the scope of papers for each issue well diversi-
fied.

There were turned over to the Editor this year some
one hundred manuscripts ranging in priority of time
from one month to two years. Those papers which
pertained to such highly specialized subjects that the
reader-interest would be negligible were returned to
their respective authors so that they might be sub-
mitted to a specialized journal. The papers which were
manifestly too long to hold the interest of the general
practitioner or whose subject matter did not appear to
warrant such extensive use of space were returned to
their respective authors with a request that they be
condensed ; most of which requests were fulfilled.

It is believed that the use of many paragraph and
sub-headings, extra spacing and the use of bold face
type has improved the reader-interest in the scientific
papers. While this takes extra time on the part of
the Editor it seems definitely worth it. In the same
category, the use of biographies of the authors and
cuts, when already available, also add to the value.

During the past year the Editor has written and
published forty-five editorials. Each editorial has been
submitted to each member of the Publication Commit-
tee in order that there may be no conflict with the
policy of The Council. Eleven of these editorials were
reprinted in nine other state medical society journals
and two more were quoted.

Two departments were instituted: “You and Your

Government,” and “You and Your Business” under
which heads a reader who may be interested would
be able to find the material desired with the least pos-
sible inconvenience.

The general .physical make-up of The Journal has
also been changed during the year in an effort to make
its appearance more modern and yet not lose the
dignity of a scientific journal.

Only one typographical error has been invited to
the Editor’s attention during the past year.

Before outlining the plans for the coming year the
Editor wishes to thank Dr. Haughey and his Publica-
tion Committee who have been most helpful and co-
operative, and the Bruce Publishing Company who have
lent every available facility both physical and technical.
Without the aid of these adjuncts and Secretary Foster
and Mr. Burns it would have been impossible to have
accomplished these changes. To all of them and espe-
cially to Dr. Haughey and Mr. Burns, the Editor is
deeply indebted.

Program for 1941

The so-called “throw-away” journals are simply
“pirates” in the publication field since they abstract
articles published in legitimate journals and print them
to attract a certain class of readers in order to sell
advertising which should go to the legitimate journals.
They have been troublesome to all of us. In an attempt
to take away some of their appeal and in order to
provide the readers of The Journal with abstracts

February, 1941

from articles published in other state journals and
also to provide national scope for authors who publish
articles in The Journal of the Michigan State Medical
Society, we are instituting, this year a plan by which
the author (when his manuscript is accepted) will sub-
mit a short abstract of the highlights of his paper.
These will be made available at the time of publication
to the other state journals and in time a system will
be worked out whereby the readers of The Journal
of the Michigan State Medical Society will have avail-
able, in abstract form, the cream of all scientific articles
published in the United States.

Arrangements have been made with the Wayne Uni-
versity College of Medicine to publish each month, be-
ginning in January, a clinico-pathological conference
in concise and interesting form. It is believed that
these will be very popular since they will contain only
pertinent and important facts. Arrangements have been
made to publish these in the same form as other scien-
tific articles since the average reader shies from long
articles in small type. The Publication Committee has
authorized the allowance of one or two complimentary
cuts to accompany these clinico-pathological conferences.

There has been a satisfactory response to the car-
toons which it is hoped will be a regular feature of
The Journal. Dr. C. L. A. 'Oden has been most kind
in giving freely of his skill.

The Editor would like to end this report with a
plea to the Councilors to forward to the Editor any
comments which they may hear in their districts. It
is very difficult to induce the readers to criticize by
letter. Especially desirable are any suggestions which
would make The Journal more readable, since a jour-
nal which is not read should not be published.

Roy Herbert Holmes, M.D., Editor.

The report was referred to the Publication Commit-
tee.

6. The Report of the Publication Committee was
presented by the Chairman, Dr. Haughey.

REPORT OF THE PUBLICATION
COMMITTEE— 1940

Your Committee met January 10 and considered
the following matters :

1. The Editor gave a report on the year’s activities.

2. The Journal Budget was studied, and motion was
made by Drs. DeGurse-Beck that this committee recom-
mend to the Finance Committee that an increase in
the Editor’s Expense of $200.00 (from $600 to $800)
be made. Carried unanimously.

3. Advertising was generally discussed. The com-
mittee felt that the acceptance of the AMA Councils
and Committees on indicated products should be con-
tinued as a policy of The Journal, and authorized
Mr. Burns, on motion of Drs. DeGurse-Umphrey, to so
inform particular firms which were prospective adver-
tisers. Carried unanimously.

4. Reprints. — ^The request of a firm for permission
to make reprints of an article which appeared in the
MSMS Journal was studied. This firm is not an ad-
vertiser. Motion of Drs. Beck-Perkins that the mat-
ter be referred to Mr. Burns to handle — to the effect
that permission to make reprints of MSMS Journal
articles is given only to authors, and to advertisers
when specifically authorized by the Publication Com-
mittee. Carried unanimously.

5. Blue Book. — The Wisconsin Blue Book, and the
high expense involved in the printing of this legal
summary, were discussed. Motion of Drs. DeGurse-
Beck that such a blue book for Michigan be not author-
ized at this time, as much of the material is being pub-
lished in digested form in the MSMS Journal in the
“You and Your Business” column. Carried unanimously.

6. Matters presented by the Editor:

137

MID-WINTER MEETING OF THE COUNCIL

(a) Tuberculosis Abstracts, to be used as fillers in
The Journal, were discussed, and authorized. They
are to be used for a limited time to ascertain if there
is any interest.

(b) Color for The Journal was discussed. Motion
of Ehs. DeGurse-Perkins that green pages be used in
the March, 1941, Journal, as an experiment. Carried
unanimously.

(c) Column for experimental work. This was given
full study and was authorized by the Publication Com-
mittee.

Respectfully submitted,

Wilfrid Haughey, M.D., Chairman.

O. O. Beck, M.D.

T. E. DeGurse, M.D.

Roy C. Perkins, M.D.

C. E. Umphrey, M.D.

The report zvas referred to The Finance Committee.

7. Report of Medical Legal Cases pending was pre-
sented by Dr. Hyland, received and placed on file, on
motion of Drs. Riley-Cummings. Carried unanimously.

8. Committee Reports. — The -following reports of
committees were presented :

(a) Legislative Committee. — Report from Executive
Secretary Bums. The various items, including neces-
sary amendments to the afflicted child act, were thor-
oughly discussed. Motion of Drs. Moore-DeGurse that
a committee be appointed to review the various recom-
mendations made and to refer back to The Council at
its meeting on January 12. Carried unanimously.

Committee : Drs. Moore, Chairman ; Cummings,

Haughey, Carstens, Urmston.

Motion of Drs. DeGurse-Sladek that the report of
the Legislative Committee be accepted and approved.
Carried unanimously.

(b) Midzvifery (from Maternal Health Committee
report). — The case of People vs. Hildy was presented
by the Executive Secretary and thoroughly discussed.
Motion of Drs. Cummings-Barstow that this matter
be referred to the MSMS Legislative Committee to
send to the State Board of Registration in Medicine
with the suggestion that the State Board consider and
take action toward necessary changes in the Medical
Practice Act to clarify this midwifery problem. Car-
ried unanimously.

Field representatives in obstetrics (from Maternal
Health Committee) were discussed by Dr. Cummings,
who felt that this work should be educational, not
practicing or doing private consultations. The Secretary
was instructed to insert in letters going to county medi-
cal societies scheduling field representatives in obstetrics
a paragraph containing the above recommendation.

(c) Committee on NY A Health Program. — This re-
port was presented and discussed. Motion of Dr.
Holmes-several that NYA Health Consultant Carey be
requested to send detailed information concerning pro-
cedures and the per diem arrangement, in order that
these facts can be presented concisely to the county
medical societies; also to send a copy of the fee
schedule to be used in those counties too small to use
the per diem arrangement. Carried unanimously.

Dr. Umphrey advised that the Michigan- Society of
Roentgenologists objected to the x-ray phase of the
NYA program. This was thoroughly discussed, during
which Dr. Urmston presented the x-ray arrangement
at Hurley Hospital, Flint. Motion of Ehs. Cummings-
Umphrey that The Coimcil endorses the attitude of
the x-ray society but inasmuch as the subject is tech-
nical and a matter of economics, it recommends the
X-Ray Society contact Dr. Carey direct, in order that
the problem can be more readily appreciated. Car-
ried unanimously.

(d) Postgraduate Medical Education Committee. —
Report was presented by Dr. Cummings, and approved
on motion of Drs. Riley-Kolmes. Carried unanimously.

President Urmston’s appointments of Drs. Norris and

Pino to the Postgraduate Medical Education Committee
were confirmed, on motion of Drs. Huron-Cummings.
Carried unanimously.

(e) Preparedness Committee report was read, con-
taining the recommendation that letters be sent to all
physicians who have not returned their AMA medical
preparedness questionnaires. Motion of Drs. Holmes-
Riley that lists of the non-signers be sent to the
medical preparedness committee in each county or dis-
trict for personal contact, except Wayne County. Car-
ried unanimously. Motion of Drs. Haughey-Cummings
that individual letters be sent to physicians in Wayne
County who have not completed their questionnaires.
Carried unanimously. Motion of Drs. DeGurse-Huron
that the report of the Preparedness Committee, as
amended in the matter of sending out the letters, be
adopted. Carried unanimously.

9. Voluntary Liens in Accident Cases. — The Execu-
tive Secretary was invited to give a report on this
activity which culminated successfully in adoption of
an agreement on January 8, 1941. Motion of Drs. De-
Gurse-Barstow that this agreement be approved and
adopted by The Council and' be published in the MSMS
Journal. Carried unanimously. Motion of Drs.
Haughey-Holmes that Dr. A. S. Brunk be appointed as
the MSMS representative to the Conference Committee.
Carried unanimously. Motion of Drs. Cummings-Riley
that the Executive Secretary be thanked for the inaug-
uration and development of this project. Carried unan-
imously.

Presentation of Gavel to the Chairman. — A gavel was
presented to Council Chairman Brunk by Executive
Secretary Bums as an expression of his appreciation of
Dr. Brunk’s counsel during the past eleven years.

The meeting was recessed at 12:10 p.m.

SECOND SESSION

The Second Session convened at 1 :30 p.m., with all
who answered to the roll call at the First Session
being present.

10. Communications from the Wayne County Medi-
cal Society re (a) the barbiturates bill to include
sulfanilamide ; and (b) amendments to the Medical
Practice Act, were presented and discussed. Motion of
Drs. Umphrey-Riley that The Council urges the State
Board of Registration in Medicine to offer necessary
amendments to the Medical Practice Act at the 1941
Legislative Session, and it urges the State Health Com-
missioner to offer a barbiturates bill, including the
sulfanilamide group to the 1941 Legislature, the aid
of the MSAIS Legislative Committee being proffered
to these two state departments in the passage of these
bills. Carried unanimously.

11. Additional Michigan Facilities for Care of In~
fantile Paralysis Cases. — Dr. Barstow presented a
project for the care of these cases in Michigan, which
was thoroughly discussed and referred to a committee
composed of the Chairman of The Council, the Secre-
tary and the Executive Secretary to draft a suitable
resolution and to submit same to The Council for final
approval.

Subsequently the Committee presented the following
resolution :

“Whereas, Large sums of money are being collected in Mich-
igan each year for the care and treatment of infantile paralysis
c&s&s

“Be It Resolved, That The Council of the Michigan State
Medical Society approves of the establishment in the state of
additional special facilities for the care and treatment of such
cases.”

Motion of Drs. Riley-Miller that the report of the
committee be adopted. Carried unanimously.

12. Preparedness Committee. — The matter of the
personnel of the Medical Preparedness Committee of
the State Society was discussed and, on motion of
Drs. Holmes-Moore, laid on the table until the Mid-
summer meeting of The Council. Carried unanimously.

Jour. M.S.M.S.

138

MID-WINTER MEETING OF THE COUNCIL

M.M.S. PROGRESS REPORT

13. Michigan Medical Service. — Dr. Carstens gave
a progress report as follows, which was accepted and
placed on file, on motion of Drs. Sladek-Perkins. Car-
I ried unanimously.

j Enrollment of Subscribers

The following is the cumulative number of persons
enrolled :

Month Plan Plan Total

i Medical Service Surgical Benefit Enrollment

March 1,360 58,658 60,118

April 1,341 60,368 61,709

May 1,352 61,783 63,135

June 1,416 63,646 65,062

July 1,594 65,388 66,982

August 1,700 65,749 67,449

September 1,758 67,558 69,316

October 4,346 86,050 90,396

November 4,677 99,243 103,920

December 4,956 112,594 117,550

Registration of Doctors

The number of physicians who have registered with
Michigan Medical Service has increased steadily. As
of November 30, 1940, there were 3,321 doctors of
medicine registered with Michigan Medical Service —
approximately three-fourths of the total possible num-
ber.

In two county medical societies, 100 per cent of the
members are registered with Michigan Medical Service
and in thirty-two others, from 75 per cent to 99 per cent
of the members are registered.

Services and Payments to Doctors

During the past nine months, 4,625 subscribers have
received services through Michigan Medical Service
for which 1,337 doctors of medicine will receive in
excess of $194,000.

Payments have been made to doctors in 70 of the
83 counties in Michigan and one out of every four
doctors has been paid through Michigan Medical Serv-
ice for services to subscribers.

The average payment for a patient under the Sur-
gical Benefit Plan has been $47.11 ; for a patient under
the Medical Service Plan, $16.27 ; or an average of
$38.89 per patient.

14. Reports of Individual Cowncilors. — The Chair
called upon each Councilor to give a report of the
condition of the profession in his district. These re-
ports were given verbally and were generally to the
effect that the profession is working together har-
moniously and making good progress in scientific and
social endeavor.

The meeting was recessed at 3 :50 p.m.

THIRD SESSION

The Third Session Convened at 8 p.m. with all
who answered the roll call at the First Session being
present.

15. The Auditor’s Report was presented in brief by
Dr. Moore, who also read the minutes of the Finance
Committee meeting of January 10, 1941, including
MSMS Budgets for 1941.

REPORT OF THE FINANCE COMMITTEE

Your Committee met January 10 and considered the
following matters :

1. Auditor’s Report. — Chairman Moore reviewed the
report of Ernst & Ernst’s annual audit of the Society’s
books for 1940.

2. Net W orth. — Motion of Drs. Morrish-Cummings
that the net worth of the Society should not exceed
at any time $50,000. Carried unanimously.

3. Motion of Drs. Cummings-Barstow that $7,500
be invested in U. S. Government bonds, preferably
U. S. Savings Bonds. Carried unanimously.

4. Budget. — The proposed 1941 budget was considered
by the Committee. Motion of Drs. Morrish-Cummings
that the Committee recommended that the salary of the

February, 1941

Executive Secretary be set at $8,000. Carried unani-
mously. The tentative budget was then agreed upon for
presentation to The Council.

Vernor M. Moore, M.D., Chairman.
W. E. Barstow, M.D.

H. H. Cummings, M.D.

R. S. Morrish, M.D.

O. D. Stryker, M.D.

BUDGET FOR 1941

INCOME

4,200 members at $12 (plus and dues of new

members) $51,000.00

Net Income from Journal

Interest 100.00

Miscellaneous Income 100.00

Total Income $51,200.00

Less allocation to The Journal at $1.50 6,300.00

Net Income $44,900.00

APPROPRIATIONS :

Administrative and General

Medical Secretary Salary $ 3,600.00

Executive Secretary Salary 8,000.00

Other Office Salaries 5,100.00

Extra Office Help 1,020.00

Office Rent 1,260.00

Printing, Sta. & Supplies 1,000.00

Postage 900.00

Insurance and Fidelity Bonds 190.00

Auditing 265.00

New Equipment and Repairs 300.00

Telephone and Telegraph 800.00

Michigan Sales Tax 75.00

Pay roll taxes 154.00

Miscellaneous 250.00

Total $22,914.00

Less expenses redistributed to Journal 1,800.00

Total Administration and General $21,114.00

Public Relations Bureau (authorized by 1940 House
of Delegates) :

Salary $ 2,400.00

Travel 400.00

Stenographic Service 600.00

Office Expense 500.00

Total for Public Relations Bureau $ 3,900.00

Society Expense

Council Expense $ 3,000.00

Delegates to AMA 500.00

Secretaries Conferences 1,000.00

General Society Travel Exp 2,000.00

Secretary’s Letters 500.00

PublicaUon Expense 200.00

Reporting Annual Meeting 140.00

Education Expense 2,000.00

Sundry Society Expenses 1,200.00

National Conf. on Medical Service 200.00

Organizational Expense 1,000.00

Legal Expense 500.00

Woman’s Auxiliary — Annual Meeting 200.00

Contingent Fund 766.00

Total $13,206.00

Less gain from Annual Meeting 2,320.00

Total Society Expense $10,886.00

Committee Expense

Legislative Committee $ 2,000.00

Distribution of Medical Care 150.00

Joint Committee on Health Education 850.00

Postgraduate Education 2,400.00

Preventive Medicine 200.00

Cancer Committee 1,000.00

Child Welfare 250.00

Iodized Salt 100.00

Heart & Degenerative Diseases 100.00'

Industrial Health 200.00

Maternal Health 100.00

Mental Hygiene 50.00

Radio 25.00

Syphilis Control 325.00

Tuberculosis Control 100.00

Public Relations Committee 500.00

Ethics Committee 100.00

Scientific Work Committee 200.00

Medical Preparedness 100.00

Sundry Other Committees.. 250.00

Total Committee Expense $ 9,000.00

GRAND TOTAL $44,900.00

139

MID-WINTER MEETING OF THE COUNCIL

BUDGET FOR THE JOURNAL, 1941

INCOME

Subscription from members $ 6,300.00

Other subscriptions 200.00

Advertising Sales 10,000.00

Reprint Sales 1,500.00

Journal cuts 150.00

Total Journal Income $18,150.00

EXPENSES

Editor’s Salary $ 1,200.00

Editor’s Expense 800.00

Expense of prior year

Printing and mailing 11,300.00

Cost of reprints 1,500.00

Allocation of administrative and general office expense 1,80'0.00

Discounts and commissions on advertising sales 1,300.00

Postage 2.50.00

Total Journal Expense $18,150.00

Motion of Drs. DeGurse-Sladek that the budgets as
presented be adopted. Carried unanimously. Motion of
Drs. Moore-Huron that the Finance Committee report
be adopted. Carried unanimously.

Bills payable were presented and ordered paid on
motion of Drs. Perkins-DeGurse. Carried unanimously.

16. The Report of County Societies Committee in-
cluding the Reference Report was presented by Dr.
Sladek.

REPORT OF THE COUNTY SOCIETIES
COMMITTEE

Your Committee met January 10 and considered the
following matters :

1. The Committee reviewed the list of twenty-three
counties which have not sent in the resolution calling
for a thirty-year extension of the Charter of the Michi-
gan State Medical Society, and recommend that the
Councilors contact each Society in their respective Dis-
tricts which have not sent in the resolution, urging them
to do so as soon as possible.

2. The recommendation of the Radio Committee to
the House of Delegates, 1940, which was approved b)'
the House, and which is as follows ; “That the State
Society and/or the Joint Committee on Health Educa-
tion set up some method for evaluation of the radio
programs, and that some effort should be made to co-
ordinate the radio programs on medical subjects now
being broadcast by the U. of M., Wayne County Med-
ical Society, and those sponsored by the Joint Com-
mittee on Health Education so as to avoid overlapping
and repetition,” was studied by the Committee. It was
suggested that the Councilors contact their various
societies with a view to determining the relative value
of the radio programs. The Committee also recom-
mends that the County Societies endeavor to develop
or select speakers to present talks over the radio
which will impress their audiences.

3. In accordance with the suggestion in President

Corbus’ address at the 1940 annual meeting : The

County Societies Committee agrees that some effort
should be made to stimulate the writing of scientific
articles by our membership and recommends that each
Councilor constantly stress this endeavor at his visits
to his County Medical Societies.

4. Postgraduate Medical Education. In an effort to
stimulate more interest in the Postgraduate courses we
would recommend that the Postgraduate Medical Edu-
cation Committee send out a questionnaire to all mem-
bers relative to subject matter of future postgraduate
courses. It is possible that a more acceptable subject
matter will react in better attendance.

We would also like to suggest to the Postgraduate
Committee the possibility of holding one large all-
day conference given by more outstanding lecturers in-
stead of the four weeklj^ meetings.

In view of the possible examination for certification
of proficiency to be given by our two state universities
we believe it advisable to publish a list of subjects
which were covered in the previous four years. We

feel that these examinations are a commendable addi-
tion to the postgraduate program, resulting in a cer-
tificate which will have a definite meaning.

5. We recommend that some study be instituted at
this time relative to school athletic examinations and
treatment of injured students.

E. F. Sladek, M.D., Chairman.

Wilfrid Haughey, M.D.

P. A. Riley, M.D.

W. H. Huron, M.D.

A. H. Miller, M.D.

REFERENCE REPORT OF COUNTY
SOCIETIES COMMITTEE

1. Secretary’s Report — (A) The Committee recom-
mends that remission of 1941 dues for service men
be limited to those who have been certified by County
Society Secretary as being in good standing as of
January 1, 1941, and that a form be printed in The
Journal for the county secretaries’ use.

(B) We recommend the acceptance of the Secre-
tary’s Report in its entirety, noting that this year it
exhibits the same thoroughness and clarity of analysis
of Society affairs, as it has in the past. We heartily
commend our Secretary for his zeal and diligence.

E. F. Sl.\dek, M.D., Chairman.

REFERENCE REPORT OF PUBLICATION
COMMITTEE

Motion of Drs. Sladek-Huron that the reports be
adopted was carried unanimously.

17. Reference Report of Publication Committee was
presented by Dr. Haughey to the effect that the Editor’s
Report was received and the Editor was thanked for
his good work and the progress of The Journal dur-
ing the past year. Motion of Drs. Riley-Moore that
the report of the Reference Committee be adopted.
Carried unanimously.

18. Executive Secretary to West Virginia. — The
Council approved Mr, Burns’ appearing on the program
of the M’est Virginia Medical Society Secretary Con-
ference, January 18, on motion of Drs. Sladek-Miller.
Carried unanimously.

19. Medical Testimony. — The Executive Secretary
presented the recent Supreme Court case of DeVries
vs. Owens.

The meeting was recessed at 10:05 p.m.

FOURTH SESSION

The Fourth Session convened at 10:15 a.m. January
12, 1941, with all who answered to the roll call at the
First Session being present.

20. Minutes. — The minutes of the First, Second and
Third Sessions of The Council, January 11, 1941, were
read, corrected and approved.

REFERENCE REPORT OF FINANCE
COMMITTEE

21. Reference Report of Finance Committee. — Chair-
man Moore reported as follows :

(a) Treasurer’s Report. This report was studied by
the committee and accepted with the exception of the
last line which was changed to read “Total funds in
my possession as Treasurer of the MSMS including
bonds at quoted market prices are $22,811.25 and cash
in Michigan National Bank $707.59 totalling $23,518.84.”
Motion of Drs. Sladek-Miller that the report be ac-
cepted. Carried unanimously.

(b) Trustee Hyland’s Report. The committee ap-
proved of this report. Motion of Drs. Cummings-Sladek
that this report be accepted. Carried unanimously.

(c) Publication Committee Report was approved.
Motion of Drs. Moore-Cummings that this report be
accepted. Carried imanimously. Motion of Drs. ^loore-
Cummings that the Reference Committee Report be ac-
cepted as a whole. Carried unanimously.

Jour. M.S.M.S.

140

MID-WINTER MEETING OF THE COUNCIL

REFERENCE REPORT OF AFFLICTED
CHILD LAW AMENDMENTS

22. Report of Cornmittee on Amendments to Af-
flicted Child Law. — Chairman Moore reported as fol-
I lows : The following principles were recommended ;
il 1. Personnel of Commission should be selected on
I basis of knowledge, interest and ability. Because this
is largely a medical problem, at least one doctor of
I medicine should be appointed to the Commission.

! 2. The Administrator should be a doctor of medi-

j cine. If a business manager is needed, he should be
: an assistant under the medical administrator.

I 3. The Commission should be designed the “Sick
! Child Commission.” All sick children, whether crippled
[ or afflicted, should come under this one commission.

4. Five medical coordinators to integrate the work
of the Commission throughout the state should be pro-
vided.

5. Medical Filter Boards, nominated by the county
medical societies and paid a nominal fee by the Com-
mission for investigation work, to cooperate with the
medical coordinators, should be arranged. The power
of admission and/or rejection of cases, either on medi-
cal or economic grounds, should be in the hands of
the Commission.

6. Cases needing special medical care should be dele-
gated by the medical administrator to the medical co-
ordinator to refer to doctors of medicine possessing
the necessary skill. Cases which do not need special
treatment should be cared for by local family doctor.
Cases should be transferred from the general to the
special group as circumstances demand.

7. The medical coordinator should decide the degree
of economic filtering, using the facilities of established
fact-finding agencies in this work. The Sick Child
Commission should determine the economic level of
cases to come within the jurisdiction of the Commis-
sion. Service to be rendered by the Commission to
be limited to the funds available, on the basis of need.
Hospital stay to be determined by the attending doc-
tor, with the advice of the medical coordinator in un-
usual cases.

8. Rates and fee schedules for hospitals and doctors
to be arrived at by conference between the Commission
and interested groups.

The report was discussed generally by those present.
It was pointed out that in drafting a new law, three
possibilities should be kept in mind, (1) the project
could be wholly in the hands of the state ; (2) it
could be a jointly financed affair between the respec-
tive counties and the state, or (3) it could be trans-
ferred to the State Welfare Commission. Discussion
brought out that the afflicted child should be adminis-
tered exclusively by the state, rather than dividing the
responsibility between the state and the eighty- three
counties and thus running into eighty-three methods of
handling the situation. Objections to the plan whereby
the afflicted children law administration would be trans-
ferred to the State Welfare Department were sum-
marized as follows: (1) Earmarked money is necessary
— ^not what is left over after food, clothing, fuel, shelter
have been provided. Neglect will result just as neglect
now exists in welfare cases in certain counties partic-
ularly where they have the 15 mill tax limitation.
(2) Problem of the sick child is separate and distinct
from the problem of relief — 40 per cent of the afflicted
children are not on relief, but come from the border-
line group. (3) The Welfare Department must limit its
work to indigents. (4) There would be as many types
of social welfare programs as there are counties.

The difficulty of providing for the regular needs of
medical care of afflicted children, and particularly in
case of epidemics, was discussed. It was also pointed
out that the acute emergency case should be taken
care of by the county; that the afflicted child law
should take care of those chronic conditions which can

be readily remedied, thus bring the child back to good
health and insure their becoming healthy self-supporting
citizens. Dr. Cummings stated that there should be
at least one medical man on the Commission, plus
a medical man as administrator, plus 5 to 7 medical
coordinators.

Motion of DeGurse-Moore that the recommendations
of the special committee on afflicted child amendments
be approved. Motion of Drs. Umphrey-DeGurse that
the above motion be amended as follows : and in addi-
tion that the present committee of The Council plus
the Child Welfare Committee of the MSMS be em-
powered to contact the proper agencies for the draft-
ing of the proposed bill. The amendment was carried
unanimously. The main motion was then put and car-
ried unanimously.

The Council felt that if it became probable that the
afflicted child were to be placed under the State Wel-
fare Department, the afflicted child should be divided
into two groups : 1. emergency cases, to be paid for by
the county ; and 2. chronic remedial cases to be paid
for by the State.

23. Preventive Medicine Committee report was given
by the Executive Secretary : The recommendation of
the Cancer Committee that one half of the additional
expense of Frank Power, M.D., Field Representative
in Cancer, be paid by the MSMS out of the Cancer
Committee budget (the other half to be paid by the
State Health Department) was approved on motion of
Dts. Huron-Umphrey. Carried unanimously. The rec-
ommendation of the Cancer Committee that a bill be
drafted which would provide for a cancer control pro-
gram in Michigan was discussed. The Council felt
that the Cancer Committee might well draft such a
bill to be presented to the Michigan Legislature by
some such agency as the Women’s Field Army or the
State Health Department.

24. Recommendations of Past-President Corhus, made
in his President’s Address, (a) that the young medical
graduate be encouraged to join organized medicine by
offering him reduced dues, and (b) that a committee
on Prelicensure Education be named with additional
representation from the State Board of Registration
in Medicine and the Michigan Hospital Association,
the objective of which is to develop a cooperative
plan for intern training, were presented. Motion of
Drs. Holmes-Haughey that the Chairman of The Coun-
cil appoint a committee to investigate the possibility
of carrying out these suggestions. Carried unanimously.

25. Election of Secretary. — Motion of Dr. Haughey-
several that L. Fernald Foster, M.D., be elected secre-
tary to succeed himself. Carried unanimously.

26. Election of Treasurer. — Motion of Dr. Perkins-
several that Wm. A. Hyland, M.D., be elected treasurer
to succeed himself. Carried unanimously.

27. Election of Editor. — Motion of Dr. Haughey-
several that Roy Herbert Holmes, M.D., be elected
editor to succeed himself. Carried unanimously.

28. Appointment of Executive Secretary. — Motion of
Dr. Umphrey-several that Wm. J. Burns be appointed
to succeed himself. Carried unanimously.

29. Regrets. — The Council on motion of Dr. Perkins-
several extended the sincere regrets of those present
to Councilors Hubbell and Stryker on their inability to
attend the 1941 Midwinter session, and to Councilor
Morrish who was ill and confined to his room at the
Dearborn Inn. Carried unanimously.

30. Thanks. — Chairman Brunk expressed his thanks
to the members of The Council for their attention,
hard work and cooperation. Dr. Moore, in behalf of
the members of The Council, commended the Chairman
on his excellent and smooth handling of the affairs
during the session.

31. Adjournment. — The meeting was adjourned at
12:05 p.m.

February, 1941

141

MID-WINTER MEETING OF THE COUNCIL

REPORT OF AUDITOR FOR 1940

January 4, 1941

Executive Committee of the Council,

Michigan State Medical Society,

I_>ansing, Michigan.

We have examined the balance sheet of the Michigan
State Medical Society as of December 21, 1940, and
the statements of income and expense for the fiscal
year ended at that date, have reviewed the system of
internal control and the accounting procedures of the
Society and, without making a detailed audit of the
transactions, have examined or tested accounting rec-
ords of the Society and other supporting evidence, by
methods and to the extent we deemed appropriate.

The Society was organized under the laws of the
State of Michigan on September 17, 1910, as a cor-
poration not for pecuniary profit. Action has been taken
to renew the charter which expired by lapse of time
prior to December 21, 1940. The Society is affiliated
with the American Medical Association and charters
county medical .societies within the State of Michigan.
The purposes of the Society are the promotion of the
science and art of medicine, the protection of the public
health and the betterment of the medical profession.
In the furtherance of these purposes, the Society pub-
lishes The Journal of the Michigan State Medical
Society.

Balance Sheet

A summary of the balance sheets at December 21,
1940, follows:

ASSETS

Cash

Notes and accounts receivable, less reserve

Securitie.s — at cost, less reserve

Deferrefl diaries

$.10,214.40

$ 352.27

1,073.50
37.788.63

$30,214.40

Notes receivable in the amount of $80.00, which liad been
acce])ted in settlement of 1031, 1032, and 1033 dues were
written off during the year as uncollectible.

Accounts receivable for advertising, reprints, etc., were
analyzed and classified as to date of charffe and are sliown
with the balances at December 21, 1040, as follows:

DATE OF CHARGE Amount Per Cent

October, November and December $ 857.06 78.86%

July, August and September 142.88 13.13%

January to June, inclusive 63.14 5.80%

Prior to January 1st 24.00 2.21%

TOTAL $1,087.08 100.00%

'I'lic balances due from county societies represent dues
collectetl for the Society by two county societies and
impouiulcd in depositary banks. When and if ariy of
these funds are released by the banks, the Society’s
share is to be forwarded by the county societies. No
payments were received during the year on these ac-
counts.

Based upon our analysis of the accounts receivable
and a discussion of their collectibility with employes
of the Society, it is our opinion that the reserve of
$175.(X) is sufficient to provide for collection losses an-
ticipated at the date of this report.

During the year it was determined that the Society
was subject to the Federal Insurance Contribution Act
with respect to salaries paid to employes since January
1, 1937. The employes’ share of the contributions for
the period from Jiuiuary 1, 1937, to June 30, 1940,
have been charged to them and they are paying the
Society over a period of twenty months. The tax is
now being paid currently and the employes’ shares are
being deducted from salary checks.

A schedule of securities owned is included elsewhere
in this report, which sets forth the principal amount,
cost and quoted market prices at December 21, 1940.
Unlisted securities have been valued from information
furnished by brokers as to the current bid and sale

IJAIHLTTIES

Accounts payable

Unearned income

Net worth

.$15,142.96
. 1,237.49

. 22,811.25
22.70

jirices. Securities in the principal amount of $9,{XX).00,
liaving aggregate quoted market prices of $6,tXX).00
as at December 20, 1939, were turned over to Ur. Wil-
liam A. Hyland', Trustee, in settlement of the Society’s
liability to him. Subsequently, bonds in the principal
amount of $2,000.00 were purchased from Dr. Hyland
at their approximate quoted market prices.

During the year, the Michigan Medical Service was
formally incorporated and commenced operations. The
Society advanced $10,000.00 for working capital, the
liability for which had been provided for in the pre-
ceding year, and also paid certain expenses prior to the
commencement of operations by the Michigan Medical
Service. At December 21, 1940, the total of the ad-
vances to and expenditures for the Michigan Medical
Service amounted to $17,544.45. We understand that
these advances and expenditures are to be repaid to
the Society only from earnings of the Michigan Medi-
cal Service with the permission of the Insurance De-
partment of the State of Michigan. Because of the
uncertainty of repayment of these items, a reserve has
been provided for possible loss of the total amount of
$17,544.45.

Deferred charges represent costs incurred prior to
December 21, 1940, with respect to the 1941 annual
meeting of the Society. In accordance with established
policy, such items are properly chargeable to future
operations.

Provision has been made for all ascertained liabili-
ties at December 21, 1940.

Collections of 1941 dues and overpayments of dues
for prior years have been shown as unearned income.

Income and Expense Statement

A summary of the income and expense statement for
the fiscal year ended December 21, 1940, is presented
in the accompanying schedule.

As in prior years, $1.50 of each member’s annual mem-
bership fee has been allocated to subscription income
of 'I'he Journal of the Michigan State Medical
SOCIE'I’Y.

In the accompanying summary a comparison is shown
of the budget adopted at the mid-winter council meeting
for the year 1940 with the actual results of operations
for the year.

As formally adojited, the budgets of operations of
both the Society and The Journal show expenses equal
to income. In the budget for The Journal, however,
the amount of $1,856.25 is shown under expenses as
“reserve.” In order to show the combined budgets
on the same basis as the income and expense statement,
the amount of $1,856.25 has been classified in the ac-
companying .schedule as income from The Journal.

Schedules are included herein showing the income
from The Journal and the expenses of the Society in
greater detail in comparison with the budgets of The
Journal and of the Society for the year.

INCOME AND EXPENSE STATEMENT

INCOME

Membership fees

Income from The Journal

Interest re9eivcd

Miscellaneous

Total Income

EXPENSES

Administrative and general

Society activities

Committee expenses

Total Expenses

Excess of Income over Expenses.
Other income

$46,174.02

2,740.96

829.18

326.36

$50,070.52

$19,909.71

10,696.89

5,518.64

$36,125.24

.$13,945.28

76.25

Net Income $14,021.53

Adjustments to net worth account 457.25

142

Increase in Net Worth

$13,564.28

Jour. M.S.M.S.

MID-WINTER MEETING OF THE COUNCIL

BUDGET

INCOME

Membership fees , $45,543.75

Income from The Journal 1,856.25

Interest 100.00

Miscellaneous 75.00

Total Income $47,575.00

EXPENSES

I Administrative and general $19,390.00

\ Society activities 17,783.75

! Committee expenses 8,545.00

Total Expenses $45,718.75

Excess of Income over Expenses $ 1,856.25

Other income -o-

$ 1,856.25

Adjustment to net worth account -o-

Increase in Net Worth $ 1,856.25

Examination Comments

The following comments relate to our examination
and tests of the accounting records of the Society and
other supporting evidence.

The demand and savings deposits were confirmed
by correspondence with the depositary banks and by
reconcilement of the balances reported by them to the
amounts shown in the balance sheet. The office cash
fund was counted on the morning of December 23,
1940. Bank deposits during three months of the year,
as shown in the cash receipts book, were compared
wiih the credits shown on the bank statements on file,
and the monthly totals of bank deposits as shown in
the cash receipts book where compared with the month-
ly totals of cash receipts as recorded therein. The re-
corded cash disbursements for three months of the
year were compared with canceled bank checks, in-
voices and other memoranda. To the extent of the
tests made, no irregularities were disclosed.

A listing of the individual accounts receivable was

in agreement with the controlling account. In order
to confirm the accuracy of the records, confirmation
requests were mailed to certain debtors selected by us.
To the extent of the replies received, no discrepancies
were disclosed.

Securities were examined by us on the afternoon of
December 21, 1940, and we obtained a certificate from
the bank that the safety deposit box in which the
securities are kept, was not opened subsequent to our
examination and prior to December 23, 1940.

We secured a written confirmation of the account
with the Michigan Medical Service.

We did not correspond with the recorded creditors
of the Society for the purpose of confirming the lia-
bilities at December 21, 1940 ; however, we examined
unpaid invoices, expense reports, etc., received subse-
quent to that date, to satisfy ourselves that all liabili-
ties had been provided for.

In addition to our examination of the items included
in the balance sheet, we made tests of transactions
entering into the income and expense accounts. Unused
membership certificates were examined for the pur-
pose of checking the income from dues. Interest in-
come on bonds was accounted for. Tests of advertis-
ing income were made by comparison of billings for
advertising with space used in three issues of The
Journal. We also reviewed the items charged to the
major expense accounts for the year.

Opinion

In our opinion, the accompanying balance sheet and
related statements of income and expense present fairly
the position of the Michigan State Medical Society at
December 21, 1940, and the results of its operations
for the fiscal year, in conformity with generally accepted
accounting principles applied on a basis consistent with
that of the preceding year.

Ernst & Ernst,
Certified Public Accountants.

BALANCE SHEET

ASSETS

Cash

Demand deposits

Office cash fund

Savings deposits

Accaunts Receivable

For advertising, reprints, etc....
From county societies for dues

Less reserve

December 21, 1940

$1,087.98

75.19

From officers and employees for pay roll taxes of prior years.
Securities

Bonds and stock — at cost

Less reserve to reduce to aggregate quoted market prices

Michigan Medical Service

Organizational expenditures made by the Michigan State

Medical Society

Advance for working capital

Less reserve

$1,163.17

175.00

$ 7,544.45

10,000.00

$ 2,919.56
9.28
12,214.12

$ 988.17

249.32

$26,717.25

3,906.00

$17,544.45

17,544.45

$15,142.96

1,237.49

22,811.25

Deferred Charges

Expenses in connection with 1941 annual meeting

22.70

$39,214.40

LIABILITIES

Accounts Payable

For current expenses, etc $ 311.09

Pay roll taxes 41.18 $ 352.27

Unearned Income

Dues for the year 1941 1,073.50

Net Worth

Balance at December 21, 1939 $24,224.35

Net increase for the fiscal year ended December 21, 1940.... 13,564.28 37,788.63

$39,^14.40

February, 1941

14d

MID-WINTER MEETING OF THE COUNCIL

INCOME AND EXPENSE STATEMENT
Fiscal year ended December 21, 1940

INCOME:

Membership fees ; $52,770.00

Less portion allocated to income of The Journal for subscriptions 6,595.98 $46,174.02

Income from The Journal — as shown by schedule 2,740.96

Interest received 829.18

Miscellaneous 326.36

Total Income $50,070.52

EXPENSES— AS SHOWN BY SCHEDULE:

Administrative and general $19,909.71

Society activities 10,696.89

Committee expenses 5,518.64 36,125.24

Excess of Income over Expenses $13,945.28

OTHER INCOME:

Reduction in reserve for notes and accounts receivable $ 70.00

Profit on sale of securities 6.25 76.25

Net Income $14,021.53

ADJUSTMENT TO NET WORTH:

Increase in reserve to reduce securities owned to quoted market prices 457.25

Increase in Net Worth $13,564.28

INCOME FROM ‘‘THE JOURNAL OF THE
MICHIGAN STATE MEDICAL SOCIETY”

Fiscal year ended December 21, 1940

INCOME

Subscriptions from members $ 6,595.98

Other subscriptions 122.50

Advertising sales 10,982.87

Reprint sales 2,120.23

Journal cuts 170.16

$19,991.74

EXPENSES

Editor’s salary $ 1,200.00

Editor’s expense 600.00

Expense of prior year 400.00

Printing ami mailing 9,989.06

Cost of reprints 1,765.90

Allocation of administrative and general expense.... 1,800.00'

Discounts and commissions on advertising sales 1,245.82

Postage 250.00

$17,250.78

Net Income $ 2,740.96

EXPENSES

Fiscal year ended December 21, 1940
ADMINISTRATIVE AND GENERAL

Salary of Medical Secretary $ 3,600.00

Salary of Executive Secretary 7,000.00

Other office salaries 5,100.00

Extra office help 480.00

Office rent 1,235.00

Printing, stationery and supplies 1,019.65

Postage 865.30

Insurance and fidelity bonds 187.28

Auditing .' 265.00

New equipment and repairs 137.42

Telephone and telegraph 796.70

Sales tax 30.06

Pay roll taxes — current year 127.15

Pay roll taxes — prior year 522.53

Pay roll taxes — interest and penalties 326.62

Miscellaneous 17.00

$21,709.71

Less expense redistributed to The Journal 1,800.00

$19,909.71

EXPENSES

(Continued)

SOCIETY ACTIVITIES

Council expense $ 4,176.78

Delegates to American Medical Association 887.65

Secretaries’ conferences 944.11

General society traveling expense 2,197.14

Secretary’s letters 217.20

Publication expense 2.50

Reporting annual meeting 135.75

Michigan Medical Service 783^77

Educational expenses 1,000.00

National Conference on Medical Service 242.53

Organizational expenses _o_

Legal expense 710.15

Woman’s Auxiliary — annual meeting 200.00

Sundry society expenses 1,163.15

Contingencies -Iq-

$12,660.73

Less revenue from annual meeting in excess of cost
thereof 1,963.84

$10,696.89

COMMITTEE EXPENSES

Legislation committee $ 258.27

Committee on distribution of medical care 131.56

Contribution to joint committee on health education 800.00

Preventive medicine committee 41.60

Cancer committee 888.83

Child welfare committee 217.06

Iodized salt committee 24.57

Heart and degenerative diseases committee 134.38

Industrial health committee 186.43

Maternal health committee 99.91

Mental hygiene committee 50.00

Radio committee -o-

Syphilis control committee 296.85

Tuberculosis control committee -o-

Public relations committee 102.71

Ethics committee 4.65

Membership committee 4.55

Advisory committee to Woman’s Auxiliary 4.27

Scientific work committee 166.24

Postgraduate medical education 2,041.18

Sundry other committees 65.58

Committee reserve -o-

$ 5,518.64

Total

144

$36,125.24

Jour. M.S.M.S.

MISCELLANEOUS

COUNTY SECRETARIES CONFERENCE
HELD JANUARY 19

j Secretaries from thirty-nine county medical societies
j of Michigan met in Lansing on January 19 for their
! Annual Conference. Represented also in the total
j registration of 123 were forty-five health officers, four
[ presidents of county medical societies, five officers and
\ councilors and twenty-five guests.

The secretaries were welcomed by Hewitt Smith,
M.D., Lansing, immediate past president of the Ingham
County Medical Society. The morning program, pre-
sided over by Horace Wray Porter, M.D., of Jackson,

■ included discussions by Secretary L. Fernald Foster,
M.D., President-elect Henry R. Carstens, M.D., Colonel
Harold A. Furlong, M.D., Medical Board, State Selec-
i tive Service Headquarters ; H. VanY. Caldwell, Execu-
tive Secretary of the Qeveland Academy of Medicine;
and Harold A. Miller, M.D., Chairman of the MSMS
Legislative Committee.

The health officers joined the secretaries for dinner
and the afternoon program, at which President P. R.
Urmston, M.D., presided. Mr. Joseph H. Creighton,
Director of the Intangibles Tax Division of the Mich-
igan State Tax Commission, reviewed the provisions
of the Intangibles Tax Law, with particular emphasis
on its effect on physicians. Talks were given by Ken-
: neth E. Markuson, M.D., W. C. C. Cole, M.D., T. M.
Koppa, M.D., and L. W. Shaffer, M.D., after which
general discussion was led by Carleton Dean, M.D.,
Deputy State Health Commissioner.

E. B. Andersen, M.D., Iron Mountain, Secretary of
the Dickinson-Iron County Medical Society was elected
as Chairman of the Secretaries for the coming year.

Among those present were :

County Soci-ety Secretaries. — H. Kessler, M.D., Al-
pena; A. B. Gwinn, M.D., Barry; L. Fernald Foster,
M.D., Bay ; Richard C. Crowell, M.D., Berrien ; Wil-
frid Haughey, M.D., Calhoun; T. Y. Ho, M.D., Clin-
ton; E. B. Andersen, M.D., Dickinson-Iron; B. P.
Brown, M.D., Eaton; John S. Wyman, M.D., Genesee;

I Sara Burgess, Genesee; E. S. Oldham, M.D., Gratiot-
j Isabella-Clare ; A. W. Strom, M.D., Hillsdale ; Roy R.
Gettel, M.D., Huron; R. J. Himmelberger, Ingham;
J. J. McCann, M.D., lonia-Montcalm ; Horace Wray
Porter, M.D., Jackson ; Frank L. Doran, M.D., Kent ;
H. M. Best, M.D., Lapeer ; Esli T. Morden, M.D., Le-
nawee ; H. C. Hill, Livingston ; D. Bruce Wiley, M.D.,
Macomb; C. L. Grant, M.D., Manistee; W. S. Jones,
M.D., Menominee; H. H. Gay, M.D., Midland; Flor-
ence Ames, M.D., Monroe ; C. G. Clippert, M.D., North
Central Counties; A. F. Litzenburger, M.D., Northern
Michigan; John S. Lambie, M.D., Oakland; R. J. Shale,
M.D., Ontonagon; D. C. Bloemendaal, M.D., Ottawa;
R. S. Ryan, M.D., Saginaw; J. H. Burley, M.D., St.

I Clair; J. W. Rice, M.D., St. Joseph; E. W. Blanchard,
M.D., Sanilac; R. J. Brown, M.D., Shiawassee; Wil-
lard W. Dickerson, M.D., Tuscola; J. W. Iseman, M.D.,
Van Buren; R. K. Ratliff, M.D., Washtenaw; Gay-
lord S. Bates, M.D., Wayne ; J. A. Bechtel, Wayne
County Medical Society; B. A. Holm, M.D., Wexford-
Missaukee.

County Society Presidents. — G. B. Saltonstall, M.D.,
Northern Michigan; Allan McDonald, M.D., Wayne;
C. A. E. Lund, M.D., Barry; J. Bates Henderson, M.D.,
Huron.

Councilors. — A. S. Brunk, M.D., Wayne; W. E. Bar-
stow, M.D., Gratiot ; Roy C. Perkins, M.D., Bay.

Health Officers. — T. E. Gibson, M.D., A. D. Aldrich,

February, 1941

M.D., Carleton Dean, M.D., E. R. Vander Slice, M.D.,
Paul A. Lindquist, M.D., John Monroe, M.D., Robert
F. Van, M.D., S. E. Moore, M.D. , Helen Lanting, M.D.,
R. Lanting, M.D., Lillian R. Smith, M.D., G. B.
Moffat, M.D., George Hays, M.D., Emily Ripka, M.D.,
Goldie B. Corneliuson, M.D., Marie Hagele, M.D.,
A. B. Mitchell, M.D., Sue Thompson, M.D., Clifton
Hall, M.D. , Berneta Block, M.D. , L. W. Switzer,
M.D., C. D. Barrett, M.D., F. T. Andrews, M.D., E.
V. TTiiehoff, M.D., C. H. Benning, M.D., Frank A.
Poole, M.D., Fred O. Tonney, M.D., F. R. Town,
M.D., E. J. Brenner, M.D., Lawrence A. Berg, M.D.,

L. V. Burkette, M.D., Albert C. Edwards, M.D., J. K.
Altland, M.D., M. R. Kinde, M.D., V. K. Volk, M.D.,
H. E. Cope, M.D., Edwin H. Place, M.D., Charles A.
Neafie, M.D., K. Haitinger, M.D., L. A. Potter, J. P.
Gray, M.D.

Guests. — George W. Cooley, Russell J. Darling, John
A. MacLellan, J. D. Laux, Otis F. Cook, Harry R.
Lipson, Frank G. Lark, C. K. Valade, M.D., Campbell
Harvey, M.D., F. E. Luton, M.D., Milton Shaw, M.D.,
F. E. Reeder, M.D., Frank VanSchoick, M.D., T.
Heavenrich, M.D., I. W. Green, M.D., Dean W. Myers,

M. D., Henry Cook, M.D., K. L. Burt, M.D.

THE HUMAN MECHANISM AND
THE SUBMARINE

Because the submarine, especially under conditions
of warfare, imposes certain environmental conditions
not inherent on surface ships, medical problems of a
particularly difficult nature develop in the care of the
personnel. Recently Brownf has reviewed some of the
problems faced by the medical officers responsible for
the care of men on this exacting duty. First the se-
lection of men must be especially rigid and the cri-
teria must include strong eyes, keen hearing and the
ability to equalize air pressure of 50 pounds to the
square inch on the ear drum, since this quality is es-
sential in escape training with the submarine “lung.”
Nervous stability is important, as a special nervous
strain results from this type of work. Much study has
been devoted to the vitiation of air which follows from
respiration during submergence. The upper permissible
limit for carbon dioxide is 3 per cent and the lower
limit for oxygen 17 per cent, both of these including
a margin of safety. Lethal or toxic gases have caused
serious accidents : If sea water gains access to the

storage batteries, sodium chloride will be electrolized
and chlorine evolved in dangerous volume. Another
highly toxic gas which has led to poisoning is arsine,
or arseniuretted hydrogen. Methyl chloride has also
been known to produce d^gerous poisoning in subma-
rines. Besides gases, high temperatures and high hu-
midities, especially under certain circumstances, pro-
duce serious problems during submerged operation.
Nvunerous safety devices have been developed to coun-
teract such hazards, including an analyzer to determine
the concentration of carbon dioxide in the air and
most notably the escape appliance better known as the
submarine “lung” and designed for individual escape
from the submarine. Finally, the special strain which
submarine duty imposes on the personnel requires
suitable facilities at the home base for comfort, re-
laxation and frequent leave periods. — Jour. A.M.A.,
116:235, (Jan. 18) 1941.

tBrown, C^t. E. W. : The human mechanism and the sub-
marine. U. S. Naval Institute Proceedings, 66:1608, (Nov.)
1940.

145

>f

Woman^s Auxiliary

-X

WHY READ THE BULLETIN?

(Prepared by Special Request)

By Mrs. V. E. Holcombe
President of Woman’s Auxiliary to American
Medical Association
Charleston, W. Va.

* * * For those of you who possibly may not be en-
tirely up-to-date, I might just mention the Bulletin is
merely the new name which has been given to the pub-
lication that was formerly called the News Letter. It is
an attractive little booklet, issued quarterly — price $1.00
per year. It is published for the express purpose of
furthering our fellowship, and propagating the princi-
ples and ideals of our organization. Advancement in
any organization is in direct relationship to the improve-
ment of facilities for the exchange and interchange of
facts, information, knowledge and truth, and the proper
use of those facilities.

* * * There are so many worthwhile happenings in
the medical world of today, which are interesting to
know, even if they are never used. With the question-
able and critical attitudes toward the medical profession
which have arisen in the past few years, it is important
that we “pool our assets” and present a united front to
adverse forces and influences.

Dr. Parran, Chief of the Lh S. Health Service, says
that last year was the “healthiest” year in the history
of the United States ; viz : the death rate was lowest
per capita. In spite of all “drives” and scares and
tales of neglect, the United States is the healthiest
country in the civilized world.

Even the most bureaucratic-minded and garrulous

must give the medical men of the world the credit for
this condition. Increasing the span of life from thirty-
seven years to sixty-five years in less than a century
was not accomplished by law-makers.

* * * The immediate goal of our auxiliary is to in-
crease the circulation of the Bulletin to include at least
one-fourth of our Auxiliary membership.. That means
that we should have approximately 6,000 readers. It
means that your Auxiliary must send at least one-
fourth of your membership. * * *

Ingham County

The Woman’s Auxiliary to the Ingham County Med-
ical Society opened the new season with a tea at the
home of Mrs. W. H. Welch in E^st Lansing. We had
the pleasure of hearing Mrs. Roger V. Walker of De-
troit, our State President, discuss the plans of the
State Auxiliary for the year. Other state officers pres-
ent were i\Irs. William Butler of Grand Rapids, Mrs.
Oscar Stryker of Fremont, and iMrs. A. O. Brown of
Detroit. We also issued invitations to the members
of the Ionia, Montcalm, Shiawassee and Eaton County
auxiliaries. At the meeting we pledged our support
to the National Red Cross drive during which our mem-
bers made the house to house canvass and operated
booths in prominent places of business through the
entire week.

Annually in November we entertain the members of
the Ingham County Medical Society with a Bohemian
feast which precedes the yearly Keno party of the
society. This is an event that we have enjoyed for

MICH.

RESTFUL

AND

QUIET

PRIVATE

ESTATE

CONVALESCENT
HOME FOR
TUBERCULOSIS

A MODERN, comfortable sanatorium adequately equipped for all types of medical and
surgical treatment of tuberculosis. Sanatorium easily reached by way of Michigan
Highway Number 53 to Corner of Gates St., Romeo, Michigan.

For Detailed Information Regarding Rtttes and Admission Apply

DR. A. M. WEHENKELf Medical Director, City OSfices, Madison 3312*3

WEHENKEL SANATORIEM

146

Say you saw it in the Journal of the Michigan State Medical Society

Jour. M.S.M.S.

WOMAN’S AUXILIARY

several years and receives most enthusiastic support
from all of us.

In December, we met at Mrs. D. A. Gailbraith’s
Ihome and received the greatest incentive possible for
;the Christmas season from a program in the true
IChristmas tradition, consisting of old Welch and Eng-
lish carols and readings. At this meeting we com-
pleted our plans for gifts and Christmas trees for the
Contagious Hospital and the Lansing Children’s Home
which is an annual custom with us.

Our January meeting promises to be one of unusual
interest. Our capable program chairman, Mrs. Rob-
ert Breakey, has secured for a speaker a foreign
traveler caught on a remote South Sea Island for many
months due to the interruption of shipping after the
outbreak of war, and we anticipate a large attendance.

— Mrs. C. S. Davenport, Secretary

lonia-Montcalm

The Woman’s Auxiliary of the lonia-Montcalm
County Medical Society had dinner with the Medical
Society at Winter Inn, Greenville, Tuesday, December
10. After dinner, members of the Auxiliary went to
the home of Dr. and Mrs. W. L. Bird. Mrs. Kling
called the meeting to order with nine members pres-
ent. Mrs. Kling gave a report about her trip to the
Mid-year Board Meeting. Mrs. Eichelberg, Greenville
school nurse, gave an instructive talk on health work
being done in the schools of Greenville, emphasizing
the work on inspection to guard against communicable
diseases.

— Mrs. M. a. Hoffs, Secretary

Kent County

The Woman’s Auxiliary to the Kent County Medical
Society met December 11 in the auditorium of the

Public Museum. Mrs. Guy De Boer, president, pre-
sided at the business meeting. Dr. V. M. Moore spoke
on “State Controlled Medicine.” He showed how Mich-
igan’s answer to State Medicine has been the “Mich-
igan Medical Service,” a corporation which sells med-
ical insurance to employed groups of twenty-five or
more in the low income group.

— WiLAMiNA Winter, Press Chairman

Kalamazoo County

The Kalamazoo Auxiliary was entertained by the
Academy of Medicine at the Burdick Hotel, Tuesday
evening, December 16.

George E. Bushnell, Chief Justice of the Supreme
Court of Michigan, spoke on “The Mechanics of the
Supreme Court.”

Members of the Auxiliary brought home-made candy
and gifts to be given the_ Aged People at Christmas
time. There were ninety-eight in attendance.

— (Mrs. Gerald H.) Frances Rigterink,
Publicity Chairman

Monroe County

The Auxiliary to the Monroe County Medical So-
ciety met at the home of Mrs. William W. Bond on
November 18, 1940. After a business meeting the
members sewed for the Red Cross. Later refreshments
were served by Mrs. Bond and Mrs. L. C. Blakey,
joint hostesses.

The Auxiliary met at the home of Mrs. Wm.
Acker, December 4, 1940. After the business meeting
the members sewed for the Red Cross and refresh-
ments were served by Mrs. Acker and Mrs. J. J.
Siffer, joint hostesses.

— Mrs. a. H. Reisig, Press Chairman

Here's an idea for you. Doctor—
Inviting them to have
some wholesome

Your patients, big and little,
welcome a thoughtful gesture
such as your offering them
some delicious Chewing Gum.

CHEWING GUM

makes for smiles
all around

Of course, Doctor, as you know,
chewing helps the mouth taste
clean and pleasant, helps relieve
tension and aids digestion. Also,
it makes a satisfying in-between-
meal treat.

Offer it to your patients and
enjoy the daily chewing of gum
yourself.

You’ll like chewing gum. See
how it helps make your days a
trifle easier for you.

Get several packages of delicious
Chewing Gum today. Have it handy
for your patients and for yourself.

National Association of Chewing Gum Manufacturers
Rosebanky Staten Island, New York

Yes, offering them
some Chewing Gum
helps make you
both feel friendlier
and closer.

February, 1941

Say you saiv it in the Journal of the Michigan State Medical Society

147

MICHIGAN’S DEPARTMENT OF HEALTH

HENRY A. MOYER, M.D., Commissioner, Lansing, Michigan

MIDWINTER JOINT MEETING

For the second time, a midwinter meeting of health
officers and secretaries of county medical societies was
held in January. The health officers held a two-day
session January 18 and 19 in the Hotel Olds, and the
joint session began with a 1 o’clock luncheon, January
19. P. R. Urmston, M.D., president of the Michigan
State Medical Society presided at the meeting. H. Al-
len Moyer, M.D., State Health Commissioner, led brief
discussions at the close of each of four ten-minute
papers. The four talks were on industrial health, im-
munization for babies and children, tuberculosis case
finding and the five-day treatment for syphilis.

NEW PNEUMONIA SERUM AVAILABLE

Pneumonia serum produced by an improved method
of refinement developed in the Michigan Department
of health laboratories is now available in all 47 of the
typing centers stocking state serum. This serum is
available for types 1, 2, 5, 7 and 8 pneumonia.

STATE MONEY NEEDED

State funds will be requested of the legislature for
three current activities of the Michigan Department
of Health which are now supported by federal grants.
The three and the amounts to be requested are : Indus-
trial hygiene, $35,000 annually for the fiscal years end-
ing June 30, 1942, and 1943; resort and rural sani-
tation, $25,000 a year; and venereal disease control,
$40,000 a year. The first and third activities are con-
nected with national defense production and with
military training.

MEASLES CASES DOUBLE

Half the counties of the state are now reporting
measles in a rise of cases which undoubtedly is pre-
liminary to an epidemic in the next few months.

Reported cases in December were double those of
November, and November cases were three times those
of October. The figures for the three months are : Oc-
tober 659, November 1,711, December 3,455. Total for
the year is 19,998.

Eighty-thousand case epidemics occurred in 1935
and 1938, and presumably 1941 will be another big
year. The 1940 cases reported, however, were more
than three times the cases reported in the years leading
up to the 1935 and 1938 epidemics.

“FLU” NOT REPORTED

Case reports reaching the State Health Department
have not yet reflected the prevalence of influenza
which is epidemic in a mild form in some parts of the
state. Influenza was formerly reportable only in epi-
demics, but it was made reportable generally in 1939.
In that year 2,288 cases were reported. In 1940, 378
cases were reported, 28 cases in November and 32 cases
in December.

SHIAWASSEE

The new county health unit in Shiawassee County .
started o])eration January 1. The director is Dr. T. E.
Camper, formerly director of the Iron County Health
Department. Offices of the unit are in the courthouse
at Corunna. Temporarily, until Dr. Camper completes
some special work at the University of Michigan, the
office is in charge of Dr. E. V, Thiehoff, assistant
director of the Bureau of Local Health Services. Shia-
wassee is the sixty-third county to establish full-time
public health service.

MARKED DECREASE IN SMALLPOX

Smallpox cases reported in 1939 totaled 371, the
highest annual figure in seven years. In 1940, the
number of reported cases dropped below 100 for the
first time since 1936, the total being 78. Nearly half
of the 1940 cases were reported in the last two months
of the year when 21 cases were reported in November
and December from Highland Park and 15 for the two
months from Detroit.

CRIPPLED CHILDREN*

. . . According to reliable figures there are 7,000
crippled and more than 20,000 afflicted children in Mich-
igan who need immediate care. Economic and medical
investigations show that they must look to their state
government for urgently needed medical help — yes, they
are looking to us during this session of the Legisla-
ture hoping their prayers will not be denied.

I urge this Legislature to take immediate action to
provide needed funds to assist these children. I am
advised that these funds may have to take the form
of a deficiency appropriation. I do not hesitate to
recommend such a course.

It is sound economy to rehabilitate these helpless
young people, through medical care or hospitalization,
so they may become useful and self-supporting mem-
bers of society. Neglected they will remain permanent
state charges.

During the lifetime of the Crippled Children’s Com-
mission since 1927, some 8,000 children have had phys-
ical deficiencies corrected, and have been given voca-
tional training. Latest reports show that they are
earning an average of $18.35 per week, and their
total yearly income is $7,008,000.

Experience of the last two years has proved that
the formula now used for distributing this type of
state aid is cruelly unjust. This formula specifies
that 75 per cent of the funds shall be distributed to
the counties on the basis of population and 25 per cent
on the basis of need. Monthly expenditures by the
counties are budgeted in advance and set at a fixed sum.

The fallacies of this plan were accentuated by the
severe outbreak of infantile paralysis in 1940, which
struck concentrated blows in many counties, while oth-
ers escaped with only a few cases. Moreover, the dis-
ease wrought its worst havoc in several cases in coun-
ties least able to pay.

To correct this unjust and inequitable condition, I call
to your attention the necessity for amending Act No.
283, Public Acts of 1939, so that appropriations for
crippled and afflicted children will be distributed solely
on the basis of need. This is recommended by those
familiar with this problem and I cannot urge you too
strongly to give favorable consideration to this revision.

The Act should be further revised to simplify jts
language eliminating all detailed provisions which
make it difficult to administer and which properly
should be left to the discretion of the Commission.
These revisions would be helpful in bringing additional
Federal funds to Michigan for this important part of
our social program.

Formation of committees to provide medical and
economic filters to cooperate with judges of probate
is considered a progressive step. Every necessary
measure must be taken to improve the administration
of this Act.

•Message to the Legislature by Gov. Murray D. Van Wag-
oner, reprinted from the Journal of the House of Representatives
of Michigan, Session of 1941, Journal Number II.

Jour. M.S.M.S.

148

-K COUNTY AND PERSONAL ACTIVITIES -k

President P. R. Urmston announces the appointment
of Edgar H. Norris, M.D., and Ralph H. Pino, M.D.,
Detroit, to the Postgraduate Medical Education Com-
mittee of the State Society.

* * *

The N'orthern Tri-State Medical Association will
hold its 1941 meeting in Tiffin, Ohio, on April 8. Fur-
ther announcement and program will appear in the
March issue of The Journal.

♦ ♦ ♦

Robert S. Breakey, M.D., Lansing, addressed the
Shiawassee County Medical Society in Owosso on
Thursday, January 16, on the subject “Ylodern Urology,
Diagnosis and Treatment.”

Reed M. Neshit, M.D., and Rig don K. Ratliff, M.D.,
Ann Arbor, are the co-authors of “Hypertension As-
sociated with Unilateral Renal Disease” which appeared
in The Journal of the American Medical Association,
issue of January 18, 1941.

^

St. Mary’s Hospital, Detroit, will hold its annual
Clinic Day on March 20. The conferences will be pre-
sided over by Frederick Coller, M.D., Ann Arbor;

C. G. Johnston, M.D., J. P. Pratt, AI.D., Detroit, and
other outstanding medical men.

* * *

Martha Lmigstreet, AI.D., Saginaw, was recently
chosen by the Saginaw Board of Commerce as the
“outstanding Saginaw citizen of the year,” the first
woman to receive the honor in the history of the award
which was first given in 1922. Congratulations, Doctor
Longstreet !

:j! :jc *

Leo M. Ford, J.D., author of the article “Keeping
Complete Written Records” which appeared in the
January, MSMS Journal, is attorney for the Aledical
Protective Company of Fort Wayne, Indiana. This
article was third in a series of authoritative discussions
on medical problems written by Mr. Ford for the
MSMS Journal.

* * *

The Radio Committee of the MSMS advises that
the following Health Talks were broadcast over radio
station CKLW ;

Saturday, January 11, 1941 — “Diabetes” by Geo. C. Thosteson,
M.D., Detroit

Saturday, January 18, 1941 — “Relationship of Dentistry and

Medicine” by Horton D. Kimball, D.D.S., Detroit
Saturday. January 25, 1941 — “Artificial Fever Therapy” by

Donald Francis, M.D., Detroit

Vx -

Ueethkitis

(DUE TO NEISSERIA GONORRHEAE)

SILVER PICRATE

*

.A'

^^ilver Picrate, Wyeth, ha*
a convincing record of effec-
tiveness as a local treat-
ment for acute anterior
urethritis coused by Neis-
seria gonorrheae. 0} An.
aqueous solution (0.5 per-
cent) of silver picrate or
water-soluble jelly (0.5 per-
cent) are employed in the
treotment’ ^ •

’ T. Knight, P., and Shelon-
sici, H. A., 'Treatment
of Acute Anterior
Urethritis with .Silver ,
Picrate,” Am. J. Syph.
6dn. & Ven. DIs., 2S/
201 (Makh) 1939.

February, 1941

Say you saw it in the Journal of the Michigan State Medical Society

149

COUNTY AND PERSONAL ACTIVITIES

Main Entrance

SAWYER SAMTDRIUM
White Daks Farm

Marian, Ohio

For the treatment of
Nervous and Mental Diseases
and Associated Conditions

Licensed for

The Treatment of Mental Diseases
by the Department of Public Welfare
Division of Mental Diseases
of the State of Ohio

Accredited by

The American College of Surgeons
Member of

The American Hospital Association
and

The Ohio Hospital Association

Housebook giving details, pictures,
and rates w^ill be sent upon request.
Telephone 2140. Address,

SAWYER SAMTDRIUM
White Oaks Farm

Marian, Dhia

The Van Meter Prize Award is offered by the Amer-
ican Association for the Study of Goiter, consisting of
$300 and two honorable mentions for the best essays
submitted concerning original work on problems re-
lated to the thyroid gland. The essays may cover either
clinical or research investigations, should not exceed
3,000 words, should be typewritten, double spaced, and
sent to Dr. W. Blair Mosser, 133 Biddle Street, Kane,
Pennsylvania, not later than April 1, 1941.

* ♦ *

The Internatioml College of Surgeons will hold its
Fifth International Assembly in Mexico City, August
10 to 14, 1941. Surgeons in the United States desiring
information about the presentation of papers or scien-
tific exhibits are requested to write Dr. Desiderio
Roman, Chairman of the Scientific Committee, 250 S.
17th Street, Philadelphia. For travel information, com-
municate with Dr. Max Thorek, 850 W. Irving Park
Blvd., Chicago.

*

Doctor^ remember your particular friends, the ex-
hibitors, at your annual convention, when you have
need of equipment, appliances, medical supplies, and
service. Here are ten more of the firms which helped
make the 1940 convention such a success :

Petrolagar Laboratories, Inc., Chicago
Pet Milk Sales Corporation, St. Louis
The Pelton & Crane Company, Detroit
Parke, Davis & Company, Detroit
The Muller Laboratories, Baltimore
C. V. Mosby Company, St. Louis

Michigan Medical Service-Michigan Hospital Service, Detroit
The Wm. S. Merrell Company, Cincinnati
Merck & Company, Inc., Rahway, New Jersey
The Mennen Company, Newark, New Jersey
♦ ♦ *

The Council of the Wajme County Medical Society
approved the recommendation of the Military Affairs
Committee that a Medical Mobilization Committee be
appointed to make surveys and plans for any eventu-
ality in case of a national emergency. The Military
Affairs Committee stressed the fact that Detroit is the
center of the National Rearmament program and there
is more likelihood of sabotage in the large industrial
establishments, which if struck by fire or explosion
would tax the facilities existing for medical care of
those who might be wounded. In case of war, Detroit
would be one of the first targets of the enemy’s bomb-
ing planes. The Mobilization Committee is to study
plans for rapid mobilization of the medical forces, as
well as the obtaining of supplies, the care of the in-
jured, education of the public with regard to public
health problems which air raids or other catastrophes
might bring and other problems of medical mobilization.
* * *

The Selective Service Headquarters, Washington,
D. C., recently announced the appointment of Leonard
G. Rowntree, M.D., as Chief of the Medical Division
of the Selective Service System with the rank of Colo-
nel of the Medical Corps.

In announcing the appointment of Dr. Rowntree,
C. A. Dykstra, the Director of Selective Service, said,
“We are fortunate to have such an experienced execu-
tive and widely known medical authority in charge of
this significant phase of the Selective Service program.
Dr. Rowntree’s work at Johns Hopkins Hospital and
the Mayo Clinic, and his service in France during the

150

Say you saw it in the Journal of the Michigan State Medical Society

Tour. M.S.M.S.

COUNTY AND PERSONAL ACTIVITIES

World War of 1917, make him highly qualified for his
difficult duties.” Thus one of the most prominent med-
ical men in the United States and a veteran of the
i World War is again in active service heading the
l medical profession of this country in making its con-
tribution to National Defense.

; :|c

COUNCIL AND COMMITTEE
1 MEETINGS

i 1. Sunday, December 29, 1940. — 3 ;00 p. m. — Special
I Committee on NYA Health Program, Hotel Olds,
If Lansing.

i 2. Monday, January 6, 1941 — 6:30 p. m. — Cancer

I Committee — Woman’s League Bldg., Ann Arbor.

3. Wednesday, January 8, 1941 — 6:00 p. m. — Insur-
jj ance Drafting Committee — Hotel Statler, Detroit.

4. Thursday, January 9, 1941 — 6:00 p. m. — Preventive
I Medicine Committee — Warded Hotel, Detroit.

5. Thursday, January 16, 1941 — 5 :30 p. m. — Mental
j Hygiene Committee — Eloise Hospital, Eloise.

6. Sunday, January 19, 1941 — 3 :00 p. m. — Syphilis
1 Control Committee — Hotel Olds, Lansing.

7. Sunday, January 19, 1941 — 4 :30 p. m. — Afflicted
Child Committee — Hotel Olds, Lansing.

8. Friday, January 24, 1941 — 12 :00 noon — Maternal
Health Committee — Hotel Statler, Detroit.

9. Wednesday, January 29, 1941 — 12:15 p. m. — Post-
graduate Medical Education Committee — University
Hospital, Ann Arbor.

^ ^ 4:

I COUNTY MEDICAL SOCIETY
MEETINGS

' Allegan — 'Tuesday, December 3, 1940 — 'Allegan

|| Health Center, Allegan — Annual Meeting — Election of
i Officers.

; Alpena-Alcona-Presque Isle — Thursday, December 19,

! 1940 — Annual Meeting, Election of Officers.

Bay-Arenac-Iosdo — Wednesday, January 15, 1941 —
i Bay City — Speaker : Donald C. Beaver, M.D., Detroit.
Subject: “Gynecologicivl Pathology.”

Calhoun — Tuesday, January 7, 1941 — Battle Creek —
Speaker: Norman Miller, M.D., Ann Arbor. Subject:
“Obstetric and Gynecologic Problems.”

; Delta-Schoolcraft — Wednesday, December 4, 1940 —

j Escanaba — Annual Meeting, Election of Officers.

: Dickinson-Ir*on — Thursday, January 2, 1941 — Iron

Alountain — Speakers : Drs. Boyce, Smith and Andersen.
Grand Traverse-Leelanau-Benzie — Tuesday, Decem-
i ber 3, 1940 — Annual Meeting, Election of Officers —
j Speakers : Frank Bethel, M.D., and John Sheldon,

j M.D., Ann Arbor.

Hillsdale — Thursday, January 16, 1941 — Jackson-

Met with other socities of Second Councilor District.

Ingham — Tuesday, January 21, 1941 — Lansing — An-
nual President’s Dinner — Speaker : Mr. John Bugas,

Director of the Federal Bureau of Investigation for
the Michigan District.

Jackson — Thursday, January 16, 1941 — ^Jackson — Host
to Second Councilor District Meeting.

Kalamazoo — Tuesday, January 21, 1941 — Kalamazoo —
Speaker : Frederick Coller, M.D., Ann Arbor. Sub-
ject: “Surgical Treatment of Peptic Ulcer.”

There’s no fee
for this
advice

In cases of real thirst, noth-
ing is more welcome to a
welcome guest than a high-
ball made with smooth, mel-
low Johnnie Walker . . .

★

IT’S SENSIBLE TO STICK WITH

Johnnie

^LKER

BLENDED SCOTCH WHISKY

CANADA DRY GINGER ALE, INC., NEW YORK, N. Y.
SOLE IMPORTER

February, 1941

Say you saw it in the Journal of the Michigan State Medical Society

151

COUNTY AND PERSONAL ACTIVITIES

Kent — Tuesday, January 14, 1941 — Grand Rapids —
Program : “Studies in Human Fertility.”

Manistee — Monday, December 23, 1940 — Manistee —
Annual Meeting — Election of officers.

Miiskegon — Friday, January 17, 1941 — Muskegon —
Gonadogen Sound Film.

Medical Society of North Central Counties — Wednes-
day, December 18, 1940 — Roscommon — Annual Meeting,
Election of Officers.

Oakland — Wednesday, January 8, 1941 — Rotunda Inn,
Pine Lake — Host to 15th Councilor District Meeting.

Ottawa — Friday, January 10, 1941 — Grand Haven —
Speaker : Florian E. Schmidt, M.D., showed film on
“Post-Encephaletic Parkinsonism with Bella-Bulgarian
Treatment.”

Tuesday, January 14, 1941 — Holland — Speaker: T. E.
Gibson, M.D., Lansing — Subject: “Venereal Diseases.”

St. Clair — Tuesday, January 14, 1941 — Port Huron —
Speaker: Luther Leader, M.D., Detroit — Subject:

“Surgical Lesions of the Colon.”

St. Joseph — Thursday, January 9, 1941 — Three Riv-
ers— Speaker : Langdon Crane, M.D., Highland Park —
Subject: “Newer Treatments of Pneumonia.”

Thursday, February 13, 1941 — Sturgis — Speaker :

Warren E. Wheeler, M.D., Lansing — Pediatric subject.

Shiawassee — Thursday, January 16, 1941 — Owosso —
Speaker: Robert S. Breakey, M.D., Lansing — Subject:
“Diagnosis and Treatment in Modern Urology.”

Washtenaw — Tuesday, January 14, 1941 — Ann Arbor
— Clinical Pathological Conference conducted by Carl
V. Weller, M.D., Ann Arbor.

Wayne — Monday, January 13, 1941 — Detroit — Speak-
er : Albert M. Snell, M.D., Rochester, Minnesota — -j

Subject: “Some Recent Studies on Hepatic Disease.”!

Monday, January 20, Detroit — General Practice Meet-J
ing. Symposium on Pneumonia. 1

Monday, January 27 — Detroit — Speaker: Gilbert]

Horax, M.D., Boston — Subject: “Neurosurgical Pro-
cedures for the Relief of Pain.” J

Monday, February 3 and 10 — Detroit — Speaker : Ar-i
mand Quick, M.D., Milwaukee Beaumont Lectures.

Monday, February 17 — Detroit — Speaker: Ashley A.,
Weech, M.D., New York — Subject: “The Physical and
Cerebral Developments of Normal Children.”

Monday, February 2^1 — Detroit — Speaker : James
Barrett Brown, M.D., St. Louis — Subject: “Limitatoins
and Possibilities in Reconstructive Surgery.”

West Side (Wayne County) — Wednesday, January
15, 1941 — Speaker : I. F. E. Schmidt, M.D., Chicago —
Movie on Treatment of Pneumonia and on Treatment
of Encephalitis.

=1: ♦ *

NEW COUNTY MEDICAL
SOCIETY OFFICERS
Alpena-Alcona-Presque Isle
President — H. J. Burkholder, M.D., Alpena
Vice President — E. A. Hier, M.D., Alpena
Secretary-Treasurer — Harold Kessler, M.D., Alpena
Delegate — W. E. Nesbitt, M.D., Alpena
Alternate Delegate — A. R. Miller, M.D., Harrisville
Barry

President — C. A. E. Lund, M.D., Middleville
Secretary — A. B. Gwinn, M.D., Hastings

Ferguson -Droste- Ferguson Sanitarium

4*

Ward S. Ferguson, M. D. James C. Droste, M. D. Lynn A. Ferguson, M. D.

*

PRACTICE LIMITED TO
DIAGNOSIS AND TREATMENT OF

DISEASES OF THE RECTUM

*

Sheldon Avenue at Oakes

GRAND RAPIDS. MICHIGAN

*

Sanitarium Hotel Accommodations

152

Say you sazv it in the Journal of the Michigan State Medical Society

Jour. M.S.M.S.

COUNTY AND PERSONAL ACTIVITIES

PERFECTION

VAGINAL

TAMPON

PERFECTION VAGINAL TAMPON
(Medicated) is a safe, rational and up-to-
date applicator for the topical medication
of the vaginal and cer-
vical mucosa.

ONE DOZEN
$2.00

Medication Only
Box of 50 — $2.00

•

Wool Only
Box of 50 — $2.00

Each Tampon con-
tains: Ichthammol 10
grains, Glycerite of
Boroglycerin q.s. It is
an individual applica-

tor complete with medicated suppository
and compressed Tampon of lamb’s wool
designed for easy introduction in a single
operation. Moisture-resistant cord makes
for easy removal.

PERFECTION VAGINAL TAMPON
(A Hartz Laboratory Product) is the sim-
ple, convenient and modern Tampon that
you can depend on. Write or phone for
your supply today.

LABORATORY OF

\^THE J.F.HARTZ CO.

15 29 Broadway, Detroit . . Cherry 4 6 00

PHARMACEUTICAL MANUFACTURERS • MEDICAL SUPPLIES

Delta-Schoolcraft

I President — Nathan J. Frenn, M.D., Bark River
Vice President — D. H. Boyce, M.D., Escanaba
2nd Vice President — A. R. Tucker, M.D., Manistique
Secretary-Treasurer — A. C. Bachus, M.D., Powers
I Delegate — J. J. Walch, M.D., Escanaba
I Alternate Delegate — W, A. LeMire, M.D., Escanaba
I Medico-Legal Advisor — A. S. Kitchen, M.D., Es-
canaba
Jackson

President — A. M. Shaeffer, M.D., Jackson
President-Elect — L. L. Stewart, M.D., Jackson
Secretary — Horace Wray Porter, M.D., Jackson
Treasurer — John B. Holst, M.D., Jackson
Board of Directors — R. H. Alter, M.D., Jackson —
term expires 1943

G. R. Bullen, M.D., Jackson — term expires 1942
J. D. VanSchoick, M.D., Hanover— -term^ expires
1941

Kalamazoo

President — Charles L. Bennett, M.D., Kalamazoo
President-Elect — Homer Stryker, M.D., Kalamazoo
1st Vice President — Lawrence Banner, M.D., Kala-
mazoo

2nd Vice President — Maynard Southworth, M.D.,
Schoolcraft

3rd Vice President — Gerald Behan, M.D., Galesburg
Secretary — Hazel R. Prentice, M.D., Kalamazoo
Treasurer — Carl Wagar, M.D., Kalamazoo
Delegates — I. W. Brown, M.D., Kalamazoo — 1941
Louis W. Gerstner, M.D., Kalamazoo — 1942

Alternate Delegates — Wm. Scott, M.D., Kalamazoo
Albert B. Hodgman, M.D., Kalamazoo
Kent

President — P. L. Thompson, M.D., Grand Rapids
President-Elect — Leon Sevey, M.D., Grand Rapids
Vice President — B. H. Shepard, M.D., Lowell
Secretary-Treasurer — Frank L. Doran, M.D., Grand
Rapids

Medico-Legal Representative — Joseph B. Whinery,
M.D., Grand Rapids

Delegates — A. V. Wenger, M.D., Grand Rapids
Carl F. Snapp, M.D., Grand Rapids
G. W. Southwick, M.D., Grand Rapids
A. B. Smith, M.D., Grand Rapids
P. W. Kniskern, M.D., Grand Rapids
Alternate Delegates — W. L. Bettison, M.D., Grand
Rapids

Christian G. Krupp, M.D., Grand Rapids
Daniel DeVries, M.D., Grand Rapids
O. H. Gillett, M.D., Grand Rapids
W. Clarence Beets, M.D., Grand Rapids

Marquette-Alger

President — F. A, Fennig, M.D., Marquette
Vice President — G. B. Wickstr^m, M.D., Munsing
Secretary-Treasurer — D. P. Hornbogen, M.D., Mar-
quette

Delegate — V. Vandeventer^ M.D., Ishpeming
Alternate — R. A. Burke, M.D., Palmer
Muskegon

President — Roy Herbert Holmes, M.D., Muskegon
President-Elect — E. N. D’ Alcorn, M.D., Muskegon

February, 1941

Nay you sazv it in the Journal of the Michigan State Medical Society

153

COUNTY AND PERSONAL ACTIVITIES

Ct. All worth while laboratory exam-
inations; including —

Tissue Diagnosis

The Wassermann and Kahn Tests

Blood Chemistry

Bacteriology and Clinical Pathology

Basal Metabolism

Aschheim-Zondek Pregnancy Test

Intravenous Therapy with rest rooms for
Patients,

Electrocardiograms

Central Laboratory

Oliver W. Lohr, M.D., Director

537 Millard St.

Saginaw

Phone, Diail 2-3893

The pathologist in direction is recognized
by the Council on Medical Education
and Hospitals of the A. M. A.

154

Secretary-Treasurer — Leland E. Holly, M.D., Muske-
gon

Delegates — 1 year — E. O. Foss, M.D., Muskegon
2 years — E. N. D’Alcorn, M.D., Muskegon
Medico-Legal Advisor — Geo. L. LeFevre, M.D., Mus-
kegon

Northern Michigan

President — G. B. Saltonstall, M.D., Charlevoix
Vice President — Guy C. Conkle, M.D., Boyne City
Secretary-Treasurer — A. F. Litzenburger, M.D.,
Boyne City

Delegate Wm. S. Conway, M.D., Petoskey

Alternate — Delegate — Walter M. Larson, M.D., Lev-
ering

Oakland

President — Leon F. Cobb, M.D., Pontiac
President-Elect — Otto O. Beck, M.D., Birmingham
Secretary— John S. Lambie, M.D., Pontiac
Treasurer — Arthur Young, M.D., Pontiac
Delegates — C. T. Ekelund, M.D., Pontiac
Geo. A. Sherman, M.D., Pontiac
Richard E. Olsen, M.D., Pontiac
Alternate Delegates — Z. R. AschenBrenner, M.D.,
Farmington

Bertil T. Larson, M.D., Pontiac
C. G. Darling, M.D., Pontiac
Eaton

President — Bert Van Ark, M.D., Eaton Rapids
Vice President — C. J. Sevener, ALD., Charlotte
Secretary — B. P. Brown, ALD., Charlotte
Treasurer — H. W. Hannah, AI.D., Charlotte
Delegate — Paul Engle, AI.D., Olivet
Alternate Delegate — F. W. Sassaman, AI.D., Charlotte
Gratiot-Isabella-Clare

President — R. L. Waggoner, AI.D., St. Louis
President-Elect — D. K. Barstow, AI.D., St. Louis
Secretary-Treasurer — E. S. Oldham, AI.D., Brecken-
ridge

Delegate — AI. G. Becker, AI.D., Edmore
Alternate — W. L. Harrigan, AI.D., Alt. Pleasant

Oceana

President — Charles Flint, AI.D., Hart
Vice President — Walter Lemke, AI.D., Shelby
Secretary-Treasurer — ^W. Gordon Robinson, AI.D.,
Hart

Delegate — Merle Wood, AI.D., Hart
Alternate Delegaate — Fred Reetz, AI.D., Shelby

Mecosta-Osceola

President — V. J. AIcGrath, AI.D., Reed City
1st Vice President — Thomas Treynor, AI.D., Big
Rapids

2nd Vice President — Paul Ivkovich, AI.D., Evart
Secretary-Treasurer — Glenn Grieve, AI.D., Big Rapids
Delegate — Gordon Yeo, AI.D., Big Rapids
Alternate Delegate — Paul B. Kilmer, AI.D., Reed
City

Washtenaw

President — Wm. AI. Brace, AI.D., Ann Arbor
President-Elect — Dean W. Alyers, AI.D., Ann Arbor
Secretary-Treasurer — Rigdon K. Ratliff, AI.D., Ann
Arbor

Say you saw it in the Journal of the Michigan State Medical Society

Tour. AI.S.AI.S.

IN MEMORIAM

Delegates — John A. Wessinger, M.D., Ann Arbor
Dean W. Myers, M.D., Ann Arbor
Lester J. Johnson, M.D., Ann Arbor
Alternate Delegates — C. L. Washburne, M.D., Ann
Arbor

L. E. Knoll, M.D., Ann Arbor
R. W. Teed, M.D., Ann Arbor

jHeittoriatn

A Testimony to Dr. J. G. Huizinga

We, the members of the Ottawa County Medical As-
sociation, realizing that in the passing of Dr. J. G.
Huizinga we have lost a capable, highly respected mem-
ber, do hereby testify that, as a colleague he was ag-
gressive, but always honest and loyal to his profession ;
as a citizen, he was conservative, but always ready to
help along in any worthy cause, and to support civic
improvements ; as a man, he stood fearlessly and
courageously for what he thought was right, but al-
ways tolerant and reasonable.

We sincerely regret to miss him from our member-
ship roll, but trust that we shall in the future as in the
past, derive benefit from his having been one of us.

In token of our high regard for our departed col-
league, we request our secretary to have this testimony
published in our State Journal, and to send a copy to
the family and incorporate in our minutes.

Your committee,

A. Leenhouts, M.D., Chairman
O. Van Der Velde, M.D.

R. Nichols, M.D.

LETTER TO THE EDITOR

My dear Editor ;

I thought possibly this small piece of work might be
of interest to the general medical men as well as the
Nose and Throat men.

This patient was operated upon by me for a tonsillec-
tomy under local anesthetic and returned to her home
in Detroit four or five days later. A slight cold was
present before complete recovery and this article was
sent as a result. I think this is rather clever and
thought some of the other men might enjoy it too.

C. M. M.

MERCER BODY SHOP
Repairs on all Models

at Reasonable Rates ^

Items on recent repair
of decrepit 1907 model
brought in by H. C. S,
of Detroit, Michigan

Installation of steel bands, replacing throat
cords rendered limber by 33 years’ use.

Sandpaper lining in throat — both sides; re-
moval of old smooth lining.

Blowing up of palate to 16 times normal size,
to help block throat passage.

Scraping ear drums, to render more sensitive,
plus re-wiring of Eustachian tubes, to con-
duct cold and heat sensations directly to ear
drums.

Careful gluing of dried fish scales to throat
lining on either side of tongue.

Final coating of velvety-soft fuzzy yellow paint
over surface of tongue.

Elimination of all taste buds.

TOTAL MISERY

February, 1941

DeNIKE sanitarium, Inc.

Established 1893

EXCLUSIVELY for the TREATMENT

OF

ACUTE and CHRONIC ALCOHOLISM

Mild Neuropsychic Cases
Admitted

1571 East Jefferson Avenue
Cadillac 2670 Detroit

A. JAMES DENIKE, M.D.

Medical Superintendent

Cook County

Graduate School of Medicine

(In Affiliation with Cook County Hospital)

Incorporated not for profit
ANNOUNCES CONTINUOUS COURSES

SURGERY — Two Weeks Intensive Course in Surgical
Technic with practice on living tissue, starting every
two weeks. General Courses One, Two, Three and
Six Months; Clinical Courses; Special Courses. Rectal
Surgery every week.

MEDICINE — Two Weeks Intensive Course starting
June 2nd. One Month Course in Electrocardiography
& Heart Disease every month, except August and
December.

FRACTURES & TRAUMATIC SURGERY— -Two
Weeks Intensive Course starting March 10 and May
5. Informal Course every week.

GYNECOLOGY — Two Weeks Intensive Course starting
February 24 and April 7. Clinical, Diagnostic and
Didactic Course every week.

OBSTETRICS — Two Weeks Intensive Course starting
April 21. Informal Course every week.

OTOLARYNGOLOGY — Two Weeks Intensive Course
starting April 7. Informal and Personal Courses every
week.

OPHTHALMOLOGY — Two Weeks Intensive Course
starting April 21. Informal Course every week.

ROENTGENOLOGY — Courses in X-Ray Interpretation,
Fluoroscopy, Deep X-Ray Therapy every week.

General, Intensive and Special Courses in
All Branches of Medicine, Surgery and
the Specialties.

TEACHING FACULTY — ATTENDING
STAFF OF COOK COUNTY HOSPITAL

Address:

Registrar, 427 South Honore St., Chicago, Illinois

Say you saw it in the Journal of the Michigan State Medical Society

155

READING NOTICES

LABORATORY APPARATUS

Coors Porcelain
Pyrex Glassware
R. & B. Calibrated Ware
Chemical Thermometers
Hydrometers
Sphygmomanometers

J. J. Baker & Co., C. P. Chemicals
Stains and Reagents
Standard Solutions

• BIOLOGICALS*

Serums Vaccines

Antitoxins Media

Bacterins Pollens

We are completely equipped and solicit
your inquiry for these lines as well as for
Pharmaceuticals, Chemicals and Supplies,
Surgical Instruments and Dressings.

RUPP & BOWMAN CO.

319 SUPERIOR ST., TOLEDO, OHIO

86c out of each $1.00 gross income
used for members benefit

PHYSiaANS CASUALTY ASSOCIATION
PHYSiaANS HEALTH ASSOCIATION

Hospital, Accident, Sickness

W INSURANCE

For ethical practitioners exclusively

(52,000 Policies in Force)

LIBERAL HOSPITAL EXPENSE
COVERAGE

For
$10.00
per year

$5,000.00 ACCIDENTAL DEATH

$25.00 weekly indemnity, accident and sickness

For
$33.00
per year

$10,000.00 ACCIDENTAL DEATH

$50.00 weekly indemnity, accident and sickness

For
$66.00
per year

$15,000.00 ACCIDENTAL DEATH

$75.00 weekly indemnity, accident and sickness

For
$99.00
per year

38 years under the same management

$1,850,000 INVESTED ASSETS
$9,500,000 PAID FOR CLAIMS

$200,000 deposited with State of Nebraska for pro-
tection of our members.

Disability need not be incurred in line of duty—
from the beginning day of disability.

-benefits

Send for applications, Doctor, to

400 First National Bank Building Omaha, Nebraska

READING NOTICES

THREE-QUARTERS OF A CENTURY FOR
PARKE, DAVIS & COMPANY

The year 1941 marks the Diamond Anniversary of
the^ founding of Parke, Davis & Company, a firm
which had its inception in a small drug store in the
City of Detroit, Michigan, -and which, during the past
seventy-five years, has become the world’s largest
makers of pharmaceutical and biological products.

From the very beginning, back in 1866, Parke. Davis
& Company has engaged in research work with the
object of making available to pharmacists and phy-
sicians, medicinal preparations of the highest degree
of accuracy.

In the early 70’s, pharmaceutical progress meant
the discovery of new vegetable drugs. Energetic — and
extensive — explorations gave to the medical profes-
sion such valuable and widely used drugs as Cascara
and Coca. Then, in 1879, came one of Park, Davis’
greatest contributions to pharmacy and medicine — the
introduction of the first chemically standardized extract
known to pharmacy. Desiccated Thyroid Gland, the
first endocrine product supplied by the Company, was
introduced in 1893. One year later, Parke, Davis estab-
lished the first commercial biological laboratory in the
United States. In 1897 came the introduction of the
first physiologically assayed and standardized extracts.
And throughout these early years, the fundamental
Parke, Davis policy — precision in pharmaceutical manu-
facture— was crystallizing.

Since the turn of the century, progress of the Com-
pany has continued apace. An aggressive program of
research has been zealously pursued, marked by the
introduction of many important medicinal products.
Diversified research activities cover the major phases
of medical^ treatment — including the endocrine, biolog-
ical, vitamin, and chemotherapeutic — and new discov-
eries are carefully evaluated through the Company’s
extensive facilities for clinical investigation.

The Company’s home offices and research and manu-
facturing laboratories in Detroit occupy six city blocks
on the Detroit Riverfront, adjacent to the Detroit-Walk-
erville ferry, which connects the City of Detroit with
the Province of Ontario, Canada.

A beautiful farm of 700 acres, known as Parkedale
and located near Rochester, Michigan, about thirty
miles from Detroit, is utilized for the production of
antitoxins, serums and vaccines, and for the cultiva-
tion of medicinal plants.

In addition to its Detroit headquarters, branches and
depots are maintained in important cities throughout
this country, and the world.

STATUS OF THE MEAD JOHNSON
VITAMIN A AWARD

Meeting in New York, June 4, 1937, the Judges stated
that the presentation of the Award “at this time is not
warranted since no clinical investigation on vitamin A
has yet been published which completely answers any
of the objectives of the original proposal. The Judges,
therefore, agreed to defer further consideration of the
granting of this award until December 31, 1939. This
action was taken because of the existence of pronounced
differences of opinion among investigators as to the
reliability of any method yet proposed for determining
the actual vitamin A requirements.’’

On November 19, 1940, the Judges met at Memphis
and stated that “considerable progress in research with
vitamin A has been made, principally along two main
lines of endeavor. The fields showing most promise
are those involving dark adaptation and blood serum
studies. The Judges feel that there is still too much

Jour. M.S.M.S.

156

Say you saw it in the Journal of the Michigan State Medical Society

THE DOCTOR’S LIBRARY

, uncertainty about the relative merits of several inves-
, tigations to warrant making the award at this time.
It was, therefore, agreed that the giving of the award
be postponed until clear resolution of various factors
is achieved.”

The sum of $15,000, called for by the Main Award,
, remains as a cash deposit in escrow with the Con-
J tinental Illinois National Bank and Trust Company
of Chicago, and will be paid immediately upon official
y notification of the Judges’ decision.

5 The Judges are: Isaac A. Abt, Chicago; K. D. Black-
I fan, Boston; Alan Brown, Toronto, Canada; Horton
'f R. Casparis, Nashville; S. W. Clausen, Rochester, N.
‘ Y. ; H. F. Helmholz, Rochester, Minn. ; E. V. Mc-
I Collum, Baltimore ; L. T. Royster, Charlottesville, Vir-
I ginia; Robert A. Strong, New Orleans, La.

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Say you saiv it in the Journal of the Michigan State Medical Society

TTve JOURNAL

of the Michigan State Medical Society

Issued Monthly Under the Direction of the Council
Volume 40 March, 1941 umber 3

Self-Inflicted Injuries
in Civil Practice*

By Deryl Hart, M.D.
Durham, North Carolina

J. Dervl Hart, M.D.

Professo}' of Surgery, Duke hniver-
s'ty. School of Medicine; in Charge of
Surgical Department, Duke Hospital,
Durham, North Carolina. Author of
numerous medical publications.

■ Self-inflicted injuries are seen by general

practitioner and specialist alike and are prob-
ably more frequent in occurrence than is gen-
erally suspected. This statement is based on
the fact that most of the cases seen by me have
been under observation either in a hospital or
in the home for from a few weeks to several
months or years before they have come under
my care. In most cases the diagnosis has not
been suspected or made, primarily because it has
not been considered. The safest rule is to mis-
trust any patient who has a lesion which fails
to heal when given appropriate treatment. This
presupposes proper consideration of the under-
lying patholog}’, such as sinus tracts, fistulse,
improper drainage, anaerobic, tuberculous or
fungus infections, etc.

No consideration will be given to the rela-
tively common major psychic disturbances which
lead to self-injury or attempts at self-destruc-

*Froni the Department of Surgery. Duke University School
of Medicine, and Duke Hospital, Durham, North Carolina.

tion. I will also omit any consideration of
injuries inflicted to avoid liability for militar}^
duty since I have had no experience with them.
Only two cases will be presented in which
financial gain played a role. The other patients
reported may have received a gain in the form
of sympathy, relief from unpleasant duties, or
satisfaction in mystifying or confounding their
relatives, friends, or physician. Some were evi-
dently feebleminded, while others were at the
age of puberty at which time they may be more
subject to mental strain. The principal interest
in this presentation lies in the individual case
reports so further discussion will be reserved
until after these are given.

Case 1. — The patient, a seventeen-year-old white girl,
was admitted to Duke Hospital on September 13, 1937,
complaining of bilateral axillary “boils” which had
been present for the past two years.

In the summer of 1935 a large “boil” near the
right axilla was incised and healed promptly. In No-
vember of the same year another “boil” appeared in
the left axilla and since that time the patient has
never been free of “boils” under both arms.

The general examination was negative except for
the manner of the patient, who was shy and retiring.
In both axillae were numerous old scars and sinus
tracts from previous “infections” andl incisions. Sev-
eral of these sinuses were draining a slight amount
of pus, but there was no evidence of an acute inflam-
matory reaction.

All laboratory studies were negative except for cul-
tures which showed only the Staphylococcus aureus. It
was impossible to find any evidence of tubercle bacilli,
fungi, or anaerobic organisms.

The draining sinus tracts were laid open and the
granulation tissue curetted out. Pathological studies
showed only a chronic inflammatory reaction. At this
time it was noted that there w^ere subcutaneous fistulse
lined with epithelium beneath each breast (Fig. 1).
The patient had given no history 'of any “infection”
in this location and had not confided their presence
to her mother, who brought her to the hospital and

!March, 1941

179

SELF-INFLICTED INJURIES— HART

who was familiar with the recurring lesions in each
axilla. On questioning she admitted that she had
had lesions beneath the breasts similar to those in the
axillae. In the axillae there were likewise numerous

the hospital immediately so that she could again be
placed in a cast with the arms extended.

The patient has remained well since these instruc-
tions were given.

Fig. 1. Fig. 2. Fig. 3. Fig. 4.

fistulous tracts which were apparently lined by epitheli-
um and from which there was no drainage (Figs. 2
and 3). In view of the symmetry and the appearance
of these lesions it was suspected that the patient had
inflicted them. We hoped that we could apply dressings
so as to make these lesions inaccessible and obtain
healing without having the patient confined to the
hospital.

During the next two and a half months every
effort was made to obtain healing by incision, curettage,
adequate drainage, and attempts to apply dressings
which would make the wounds inaccessible. The arms
were bandaged tightly against the side, with pads in
the axillae but healing could not be obtained. The
patient’s condition was then discussed frankly with
her family, who had a sympathetic and understanding
attitude, and she was brought into the hospital to be
kept under close observation until satisfactory results
could be obtained!. Under general anesthesia all the
epithelial ized tunnels beneath the skin in the left
axilla were opened up (Fig. 3). The granulating
areas were again laid open, and curetted or excised
(Fig. 4). The area was treated with compresses of
physiological salt solution and six days later the larger
granulating area was covered with pinch grafts.

Sixteen days after the first operation the lesions
beneath the breasts and in the right axilla were treated
in a similar manner. In the meantime, a new draining
sinus had developed in the right axilla while she was
having treatment for the left side and there was also
evidence that she had been tampering with the skin
grafts, so while she was under general anesthesia a
plaster of Paris cast was applied to her trunk and
both arms, fixing her in a double “Statue of Liberty”
position. Healing then progressed rapidly, and within
twelve days all areas had healed.

The patient was very desirous of going to visit an
aunt and was given permission to do so but in her
presence instructions were given that under any con-
dition the aunt or the mother should inspect the axillae
andi breasts daily and at the slightest sign of any
return of the condition she was to be returned to

Case 2. — The patient, an eighteen-year-old white
married woman, was admitted to the Duke Hospital on
April 22, 1940, complaining of “dry gangrene of the
hamd.” The family history was negative except that
five out of fourteen brothers and sisters had died in
infancy.

The present illness began nine days before admission
at which time she received a finger nail scratch on
the dorsum of the right hand. The wound did not
seem to be infected, but three days later a darkened
area appeared at the site of the injury. This had
increased in size, particularly during the preceding
two days, and was accompanied by tenderness and
swelling of the hand, general malaise, anorexia, slight
fever, and, on two occasions, chills. The w'ound had
been debrided and treated by her family physician.

Examination revealed nothing of importance other
than the lesion on the right hand. Over the radial
surface of the dorsum was a black gangrenous area
measuring approximately 3 cm. in diameter and about
which there was no gross inflammatory reaction. There
was no enlargement of the adjacent lymph nodes. Mo-
tion of the fingers was somewhat limited. The white
blood count was 9,800 and the hemoglobin was 90 per
cent.

Treatment. — The black eschar was removed at the
time of admission. The base of the ulcer was black,
the tendons were exposed, and several exposed veins
were thrombosed (Fig. 5). During the patient’s eleven-
day stay in the hospital under treatment with hot
saline compresses and application of zinc peroxide
the ulcer cleared up rapidly, the slough separated,
leaving a healthy granulating base. Repeated anaerobic
and aerobic cultures showed only occasional staphylo-
cocci.

After treatment for eleven days, and just before
skin grafting was to be carried out, the patient left
the hospital against advice. She stated that she w'ould
return home and talk to her physician and come back
within one w'eek for skin grafting of the area. She
has not been seen since that time.

180

Tour. M.S.M.S.

SELF-INFLICTED INJURIES— HART

Case 3. — A white girl, fourteen years of age, was
brought to the hospital because of “sores” on the
legs, arms,, and head. Two months before entry a
black spot appeared on the left shin and with sloughing

12 by 7 cms. with a definite growth of epithelium at
the margin and in areas in the base. No specific cause
to account for the persistence of the lesion could be
demonstrated. After repeated questionings the patient

Fig. 5.

Fig. 6.

Fig. 7.

Fig. 8.

of the necrotic skin an ulcer formed. During the
interval prior to admission similar lesions developed
on the dorsum of the left foot, on the scalp and on
i both wrists. The family physician sent the patient to
I the hospital because he was unable to determine the
cause of the lesions.

I The patient was shy and uncommunicative except
that she enjoyed exhibiting the ulcers and telling how
she knew in advance when and where each was going
to appear. There w-ere numerous ulcers or areas of
skin gangrene, some of which are shown in Figures
6, 7 and 8. The remainder of the physical examination
and the laboratory examinations were negative.

Further inquiry revealed the fact that the patient
had been allow’ed to ride to school because of the ap-
pearance of the lesions on the foot and later was
excused from writing wLen the black spots appeared
on the wrists. As the “disease” seemed to spread she
was released more and more from duties about the
house and farm. Although she strongly denied that
the lesions were self-inflicted, the family stated that
she had access to the lye used in making the house-
hold soap, and no new areas appeared while she was
in the hospital. With the application of saline dress-
ings the necrotic skin separated and the ulcers healed
by second intention. No new- spots had developed three
years after her discharge from the hospital.

Case 4. — The patient, a white girl, eleven years of
age, had developed a blister on the inner aspect of
the right foot ten months before admission. Following
this an ulcer formed, w^hich grew progressively larger,
although it received treatment which should have re-
sulted in healing.

Examination revealed a shy, uncooperative w'hite girl
in good physical condition. On the medial aspect of
the right foot there was a shallow ulcer measuring

finally admitted she had kept the ulcer from healing
by picking it. Her parents were informed of the situa-
tion and after obtaining their cooperation the ulcer
healed within a week.

Case 5. — The patient was an unintelligent female mill
worker twenty years of age who, over a period of
ten 5'ears, had developed recurrent areas of skin gan-
grene. She had failed repeatedl}' in school and had
advanced only to the fourth grade after seven years’
attendance.

During the examination she feigned unconsciousness,
performed athetoid movements, and was apparently
insensible to stimuli, although when she thought she
was not being watched she returned to “normal.”
There were many scars and areas of skin gangrene
on the face and extremities.* The remainder of the
examination and the laboratory studies were negative.

Under treatment healing was rapid. Her family phy-
sician reported that she remained well for only two
months, after which time the ulcers reappeared.

Case 6. — ^A white woman, thirty years of age, "was
sent to the hospital from a county home because of
a “sore” on the left foot which, three weeks before
entry, had developed as an area of skin gangrene.
Two years before she had feigned a bloody discharge
from her ear by taking blood obtained from her
gums and placing it in the external auditor}^ canal
so her physician now suspected her of malingering.

The patient ^\'as a poorly developed, mentally deficient
white woman. On the dorsum of the left foot were
five round areas of skin necrosis with little peripheral
reaction. When she was seen on her second visit three

*For illustrations of this and other cases see “Self-Inflicted
Injuries in Civil Practice,” Deryl Hart, M.D., and Randolph
Jones, Jr., M.D., The Southern Medical Journal, 29:963-973,
(October) 1936.

March. 1941

181

SELF-INFLICTED INJURIES— HART

months later the original lesions were partly healed,
but a new crop in various stages of development was
present over the lower leg and on the face. The only
treatment was the application of a plaster cast to

Fig. 9.

the leg, thus rendering the lesions there inaccessible.
Six weeks later all ulcerations, including those on the
face, had healed.

Case 7. — A white girl, nineteen years of age, was
sent to the hospital by her surgeon because an appen-
dectomy incision had failed to heal for four 3’ears after
operation. The incision had healed per primam ex-
cept for a small area at the upper end. Here a small
ulcer formed, which gradually spread until the entire
scar was involved. Diathermy, ultraviolet radiation,
various applications, and seven operative procedures
did not result in healing. IMeanwhile, various hemo-
static agents and other measures failed to control the
intermittent bleeding from the ulcer.

Examination showed a childish, over-cooperative
white girl who was quite obese but who otherwise
was in good physical condition. In the scar of a
low right para-rectus incision was a shallow ulcer
10 cm. long and 2 cm. wide. No sinus tracts could
be discovered and the base was covered with healthy
granulation tissue. Cultures from the wound pro-
duced only Staphyloccocus albus. The ulcer was
treated with saline compresses for three days and then
curetted under anesthesia and no sinus tracts were
found. The tissue obtained showed on examination
only a non-specific inflammatory reaction. At the time
of operation the skin adjacent to the wound was
painted with gentian violet and the patient placed in
a body cast. Three days later when her fingers were
found stained with the dye, the cast was extended
downward to include the thighs and to make the
wound completely inaccessible. A window was cut in
the cast over the ulcer and pinch grafts were trans-
planted to the clean, granulating area. Within seven-
teen days after admission to the hospital the ulcer had
healed (Fig. 9).

The patient, who could foretell bleeding from the
wound, after being placed in the cast cried most of
the time for forty-eight hours and sent repeated mes-
sages asking her family to come for her. Having
failed to persuade them she suddenly appeared brighter
and said, “I have a feeling that I am going to get
well.” Although no admission of self-inflicted irrita-
tion of the wound could be obtained, and against
our advice that our opinion, known to the patient, be
held over her as a means of securing her cooperation,
the surgeon who had treated her for the four years
told the family the cause of the failure to heal. She
has remained well and we feel there is no doubt as
to the cause of the non-healing.

Case 8. — A white man, twenty-one years of age, was
seen because an appendectomy incision did not heal
during a period of seven years, in spite of frequent
dressings and six operations performed to obtain
closure.

The patient was in excellent physical condition. In
the lower portion of the scar of a AIcBurney incision
was an ulcer 2.5 cms. in diameter. There was nothing
about the appearance of the wound to account for its
failure to heal and we concluded that it was being
kept open.

The skin of the entire right lower quadrant and
the ulcer were painted with gentian violet so that
it was difficult to differentiate the ulcer from the
surrounding skin. A large dressing w^s applied and
sealed to the skin with collodion. Even by changing
the dressing every two days it became progressively
more difficult to keep the edges sealed. After ten days,
when the ulcer was two-thirds healed, the patient ap-
peared with the dressing detached along the lower
border andl reported that the “discharge” was much
worse. He was shown that the “discharge” was dried
blood and on removing the dressing his attention was
called to six parallel tangential cuts in the skin, each
approximately 2 cms. long, just below the ulcer, which
itself still showed progressive healing. Since that time
he has not been seen by either his surgeon or by me.

However, six years later a representative of the
Federal Employment Agency came to seek my advice
about a “most distressing case” of a young man who
was very desirous of obtaining work and even then
had temporary employment in the postoffice during the
Christmas rush but could not work continuously be-
cause of an appendix wound of thirteen years’ dura-
tion which had never healed. As she understood I
had treated him she wanted my opinion and advice
as to what could be done. She was told that reports
on patients would not be given without the patient’s
consent, but that if she would come out with the
patient I would be glad not only to go over his case
in detail but could also probably assure her of obtain-
ing healing if the patient could be placed under my
care in the hospital for thirt}' days. Needless to say
they did not come. However, the desired result was
obtained for a year later I learned that the wound
had healed, that the patient had a job and was sup-
porting his mother.

182

Jour. M.S.M.S.

SELF-INFLICTED INJURIES— HART

Case 9. — The patient, a white man twenty-five years
of age, came to the hospital because of an unhealed
j appendix wound of nine months’ duration. He had
j been discharged from the hospital two weeks after
I the operation with the wound apparently healed but
: returned a week later, at which time it was open and
draining pus. Since that time the unhealed area had
i increased gradually in size despite various types of
; treatment that had been used. At no time had there
' been any evidence of fecal drainage.

' Examination showed a well developed man with
normal hemoglobin, white blood count, pulse, tempera-
ture, and respirations, and presenting nothing of im-
I portance, except in the right lower quadrant of the
i abdomen where there was an oval ulcer measuring
10x20 cms., with a dirty granulating base, in the cen-
i ter of which was a large area of blackened necrotic
tissue. There was no sinus tract and no evidence of
undermining at the edges. The Wassermann reaction
was negative.

Cultures of the wound showed only Staphylococcus
albus and E. coli, with no fungi or anaerobic organisms.

After four days’ treatment with compresses aided by
excision of the necrotic slough, a clean granulating
base was obtained. At this time, however, the patient
refused further treatment and left the hospital against
advice. His physician was told that the wound was
in condition for skin grafting which would be neces-
sary for early healing.

After thirty days the patient returned, giving the
history that two weeks previously skin grafts had been
applied by his physician. All the grafts had taken,
both the grafted area and the donor area were healed.

There was moderate depression in the center of the
grafted area. Below and medial to this grafted area
there was a superficial ulceration measuring 4x3 cms.
This was clean, with no sinus tract, no undermining
of the edges, no tenderness in the surrounding tissues ;
and no signs of any intra-abdominal lesion. The patient
was sent in by his physician for consultation only
and has not been under our care since that time.

A recent letter from the patient’s physician follows ;

“The area where the blisters had occurred on the
patient’s wound were grafted after his return from
Duke. This wound has healed completely except for
one place about an eighth of an inch in diameter, but
on his left leg, where I took the last grafts, he has
developed an infection similar to the one he had
in his right lower abdominal wall.

“I have kept continuous wet boric acid dressings
to this wound which has progressively gotten worse.
For the last three days I have applied 50 per cent
ichthyol ointment which was the drug that I had used!
on his abdomen just before I sent him to Duke the
first time. If you remember this patient also had
an infection around both big toe nails. I removed
the nails finally and kept wet boric acid dressings on
these toes continuously but to no avail. Fifty per cent
ichthyol ointment was applied to these toes for several
days and then the wet boric acid again and the toes
healed nicely.”

Although the patient was never openly accused of
inflicting the injuries, and was never asked by us
to admit it, the course makes such a diagnosis highly
probable.

Case 10. — The patient, a sixteen-year-old white fe-
male, came in with a complaint of nausea and vomit-
ing which had been present for the past ten weeks.
The present illness began about 8 months before

Fig. 10.

admission when she began having attacks of right
lower quadrant pain, occasionally associated with
nausea. These attacks increased in severity and in
January, 1938, the appendix was removed. Following
this operation there was a moderate bloody discharge
from the wound and three weeks following operation
she left the hospital without the wound being com-
pletely healed. One week later when she returned for
a dressing the skin surrounding the incision was in-
flamed. After a. period of two weeks, during which
time the patient was ambulatory and the wound dressed
daily, she was readmitted to the hospital since heal-
ing had not progressed satisfactorily. The skin about
the incision, which had been inflamed when the pa-
tient returned to the hospital for dressings, developed
blisters (Fig. 10). These blisters occurred before the
patient received any ultraviolet radiation, and broke
down with the discharge of a yellow material. In the
hospital the wound was dressed two to three times
a day and was treated with ultraviolet radiation. It
was two and a half months after a simple appendec-
tomy before the wound was completely healed. Fol-
lowing healing there was residual tenderness in the
right lower quadrant. After all the lesions had healed
(about two months before admission to the Duke Hos-
pital) she began to have frequent attacks of vomiting,
associated with some pain beneath the umbilicus and
in the region of her operation. The vomiting, never
associated with bleeding, had occurred immediately
after meals and had been spontaneous without nausea.
It had persisted except for one short interval and
the pain beneath the umbilicus and at the operative
site had been present constantly. There had been no
distention, no abdominal masses, and ishe had lost no
weight during this period.

Examination showed nothing of significance other
than the abdomen, where on the surface was the scar
from the appendectomy, measuring about 5 cms. in

March, 1941

183

length and 1 to 1.5 cms. in width. Scattered about
this over most of the right lower quadrant (Fig. 10)
were irregularly placed scars, some of which were
discrete and well circumscribed while others were con-
fluent. Deep palpation revealed some tenderness in
the right lower quadrant, but otherwise the abdbminal
examination was negative. The hemoglobin was 90 per
cent and the white blood count was 7,600.

Following admission to the hospital the patient,
after being served milk and crackers, was noted to
vomit only milk. The crackers had disappeared from
her tray and the nurse discovered that she secreted
these beneath her pillow and ate them at night. Gastro-
intestinal studies were entirely normal. At this time
it was learned that the patient had had a love affair
and it was the opinion of her mother that this might
have some bearing on her condition.

Psychotherapy, consisting of nothing by mouth, bi-
lateral subcutaneous salt infusions, and frequent gastric
lavages were tried with striking results.

Within eight days after treatment was started the
patient was eating and retaining her diet. On the
tenth day she was discharged, her condition being
described as good, and her gastro-intestinal system
seemingly functioning normally.

When seen ten weeks later she had had no nausea
or vomiting, had been to the beach twice during the
summer, and was enjoying life in general.

Case 11. — Another patient, who was not under my
direct care, but who was seen by me, had an appendec-
tomy incision which would not heal until she was
placed in a plaster cast and the wound skin grafted.
Then healing was rapid and she was discharged as
cured. However, she was seen several years later,
after having been in various hospitals throughout the
country, and again had an open wound in the old scar.

Case 12. — This white woman,* thirty-five years of
age, entered the hospital with the complaint of “Ray-
naud’s disease.” Her fingers had been removed piece-
meal by numerous operations. Over the end of the
fifth left metacarpal was a sharply demarcated area
of gangrene. The radial pulse in both wrists was good
and the hands appeared normal except for the lesion
described and the mutilation of previous operations.
Although the patient complained loudly of her unfor-
tunate condition and of severe pain in the hand, she
seemed quite comfortable when “off guard.” She also
insisted that amputation be done through the middle
of the fifth metacarpal, saying that otherwise the
wound would not heal.

The ulcer was excised, using nitrous oxide-oxygen
anesthesia, and, after controlling the bleeding, which
was profuse, the skin was closed and the entire hand
and forearm placed in a plaster cast. After twelve
days the cast was removed and primary healing had
occurred. When the patient saw what had been done
she cried almost continuously for twenty-four hours,
giving no explanation except that we had “fooled”

’Reported by permission of Dr. Dean Lewis.

her. She has not been heard from since leaving the
hospital.

Case 13. — A pupil nurse, twenty-three years of age,
was admitted to the infirmary of another hospital
because of a mild carbolic acid burn of the hand.
The bum healed rapidly ; however, she was kept
under observation for six months and every conceiv-
able examination made to discover why she had a
continuous elevation of temperature (101 to 104“ F,).
Nothing could be found and she was eventually dis-
charged with a diagnosis of “hyperpyrexia unexplained.”
We first saw her eighteen months later because of a
peculiar “infection” about the nail of the left third
finger. This failed to subside under treatment, and
finally the nail was removed, followed only by tem-
porary improvement. A week later, when she returned
for her daily dressing, there was a fiery red discolora-
tion of the dorsum of the hand which had somewhat
the appearance of erysipelas.

The patient was then admitted to the hospital and
the “infection” healed rapidly. Her temperature, how-
ever, remained elevated as at the time of her previous
illness, until a house officer noted that her face was
cool when her temperature, which had just been taken,
was recorded as 103° F. Her temperature was imme-
diately retaken by mouth, axillae, and rectum, using
four thermometers simultaneously, and the patient kept
under close observation. All thermometers registered
below 98.6° F. Thereafter she was closely watched
when her temperature was taken and there was no
subsequent elevation. Shortly after she left the hos-
pital, having been dismissed from her training school
as mentally unsuited for nursing, she wrote that the
hand, which was healed at the time of her discharge,
was again giving trouble.

Case 14. — An intelligent white woman, twenty-three
years of age, entered the hospital complaining of a
chronic infection about the nail of the right great toe.
One year before entry, the entire nail had been re-
moved ten days after the onset of an acute infection.
Although the nail bed had been curetted twice in the
interim and the matrix of the nail removed, the wound
would not heal.

The physical examination was negative aside from
a clean granulating ulcer occupying the position from
which the nail had been removed (Fig. 11).

The ulcer was treated with compresses and then
curetted. A dressing was applied to the toe and the
foot and the leg was placed in a plaster cast. This
was followed by prompt healing. Several weeks later
the patient returned with a blister in the scar. She was
told then that if this did not heal promptly, a shoe
would be made with a lock ; her sister with whom
she lived would be given the key, and told the nature
of her trouble. She never admitted keeping the wound
open, yet it remained healed under the salutary threat
of exposure.

Case 15. — A white man, thirty-one years of age,
entered the out-patient clinic complaining of a “boil”

184

Jour. M.S.M.S.

SELF-INFLICTED INJURIES— HART

on the back of his hand. Two years before a cigarette
burn on the left wrist resulted in an infected pustule.
Shortly afterward a crop of similar lesions appeared
progressively on the arm. About the time these healed
a red, raised area developed on the dorsum of the
left hand, was incised, and drained only serosanguine-
ous fluid. The “boil” had continued to exude bloody
fluid intermittently until the patient’s entry.

Examination showed the left arm to be pock-marked
by numerous round, regular scars extending up to
and stopping sharply at the shoulder. The “boil” on
the dorsum of the left hand was a heaped up area
of scar tissue with a small sinus in its center from
which old blood exuded.

A bandage of Unna’s paste was applied to the hand
and forearm, and when this was removed three weeks
later the “boil” had completely healed.

Case 16. — A white woman, twenty-seven years of
age, was admitted to the hospital with the complaint
of swelling and soreness of the right knee. Shortly
after an attack of acute arthritis three years before
entry, black and blue spots appeared over the right
knee. Tlie lesions had recurred and soreness in the
joint had persisted at intervals until admission.

Examination showed seyeral large swollen ecchy-
moses on the medial aspect of the knee joint which
was held flexed at an angle of ten degrees until her
attention was diverted, when it could be moved through
a normal range of motion. Aside from slight atrophy
of the right leg, the other findings were negative.

Shortly after admission, excessively dark circles un-
der her eyes were found to be caused by coloring
matter which could be wiped off. Meanwhile a new
crop of purpuric spots appeared over the knee as
the older areas faded. In spite of her objections,
a plaster cast was applied to the extremity, and when,
two weeks later, this was removed the lesions had
disappeared completely. An unhappy home situation
was admittedly the cause of many of the patient’s
complaints. After repeated conversations there was
some improvement in her mental attitude and she
left the hospital after seven weeks, improved and
able to walk. ^

The two cases which follow belong to the
group of purposeful malingerers who receive
compensation for their disability.

Case IT. — A white female mill worker, twenty-nine
years of age, was sent to the hospital by the State
Industrial Commission because of “sores” on the left
knee and stiffness of the joint Ten months before
she was supposedly bitten on the left knee by a
“scorpion,” which she described as being a small lizard.
Shortly afterward, and in the interval until admission
to the hospital, recurrent areas of skin gangrene had
appeared about the knee and the joint had become
stiff. During this time she had been receiving com-
pensation for her disability.

Examination revealed circular and dumb-bell-shaped

areas of skin gangrene over the left knee and lower
thigh. All had well defined margins except for an
occasional comma-like area of redness at their periph-
eries, where some liquid caustic had evidently been

Fig. 11.

spilled over on the skin and had been quickly wiped
off. Numerous scars of former lesions were present.
The knee was held stiff until the patient’s attention
was diverted, at which time the joint relaxed and
could be moved five to ten degrees before she noticed
the motion and again held it rigid.

Under a general anesthetic, the eschars were ex-
cised and the defects were skin grafted. With induc-
tion of the anesthesia she moved the “stiff” knee
through a normal range of motion. After operation
healing was, rapid and the patient moved the knee
freely. On discharge from the hospital all claims for
compensation were dropped.

Case 18. — Two and a half years before entry to the
hospital, this forty-year old white man stuck a nail
in his foot. Shortly thereafter he developed a pustular
eruption on the dorsum of his foot, which recurred
periodically and for which he had been receiving dis-
ability benefits.

On examination an eruption was found over the
dorsum of the foot, composed of pustules in all stages
of development. Some of these when opened contained
a small foreign body which proved to be a splinter.
Many of these small spicules were removed in the
presence of the patient and carefully preserved. The
foot was thoroughly cleaned with alcohol and a plas-
ter cast applied to include the foot and the leg.

Two weeks later, on removing the cast, the pustules
had healed and their sites, were represented by crusts.
On removing these a small spicule was seen projecting
from the under-surface of each. These likewise on
renioval were preserved. At the end of the final
examination six weeks later the foot was entirely
healed and the patient was told, in the presence of

March, 1941

185

SELF-INFLICTED INJURIES— HART

an insurance representative, and with the bottle con-
taining the spicules in front of him, that there was
no relationship between the pustules and the injury
received when he stuck a nail in his foot. He was
also told that he was not entitled to further compensa-
tion. Following this he dropped his claim.

Over a year later I was called to testify before the
North Carolina State Industrial Commission in regard
to this patient, as he had had a return of the same
symptoms and had requested that the case be re-
opened. In my testimony I emphasized the fact that
his lesions had no relationship to the olci puncture
wound,; but in. the face of pointed questioning care-
fully avoided any statement that they were self-inflicted
since this would be difficult for me to prove and
might result in personal embarrassment. After the
claim had been disallowed the Commissioner in a pri-
vate conversation stated that he gathered from my
testimony that I had an opinion about the man’s con-
dition which I was not willing to have written into
the record, and asked if I would be willing to give
it to him privately. When told that in my opinion
the lesions were undoubtedly self-inflicted, he told
me that the Commission had learned that five years
previously the South Carolina Industrial Commission
had found that the patient was drawing compensation
for injuries which had been self-inflicted.

Patients with self-inflicted injuries and with
their desire to conceal the true nature of the le-
sions and mystify the physician present prob-
lems in diagnosis and treatment which demand
all the knowledge and experience and tax the
ingenuity of the most adept. In the literature
they have received attention from men in all
branches of medicine, but as a group are sel-
dom considered in textbooks except those on
diseases of the skin. Even in our own hos-
pital files it is impossible to locate the records
of a number of similar cases since the diagnosis
for some reason (such as a relative of the patient
in the training school, or record room) was not
complete. A considerable number of these pre-
sented were found only as a result of the good
memory of members of the staff.

These lesions are far more common in adults
than in children and Jare most common about
the age of puberty, particularly in girls.

The most common lesion produced in the
female is some form of dermatitis artefacta,
while there are recorded instances of male pa-
tients who have produced a cellulitis by the in-
jection of liquid feces, saliva, crude oil, turpen-
tine, or metallic mercury. Granulomas have been
produced by the injection of paraffin or camphor,
hernise by dilatation of the external ring, and

rectal prolapse by the tearing of the sphincter
muscle. Abscesses have formed following the
insertion of thread, horsehair, or splinters be-
neath the skin, while one patient is reported to
have forced a knitting needle from an appendec-
tomy wound into the bladder. I know of one
woman who had multiple sinuses which traversed
the abdomen and thighs, produced by forcing a
crochet hook beneath the skin. (Figs. 2 and 3
show lesions which also must have been pro-
duced in some such manner.)

The classification of the patients into groups
should take into consideration the motive be-
hind the act and the degree of insight the pa-
tient has into his or her psychological processes.
No attempt will be made to classify our patients
through many can be fitted into one of the
following groups.

1. Those desiring to gain sympathy or at-
tention or to evade unpleasant duties.

2. Adult malingerers who consciously muti-
late themselves for personal gain as compensa-
tion or evasion of militaiy^ duties.

3. Those who mutilate themselves in order
to obtain a certain amount of perverted sexual
gratification.

4. Hysterical patients, usually girls, with a
subnormal intellect.

5. Patients with major psychoses who make
no effort to evade the responsibility for the le-
sions being self-inflicted.

Diagnosis

The diagnosis of conditions of this type de-
pends primarily on ruling out organic disease
and on maintaining a suspicious and inquisitive
atttitude toward all patients with lesions of a
questionable nature. To one who has seen sev-
eral cases the estimation of the personality of
the patient may be of great assistance. There
is usually an ill-definable quality about their
general reaction which is difficult to describe.
They may be over-cooperative or too insistent
that their trouble is of no consequence, and that
they can return to their daily routine. The gen-
eral appearance of frankness may be overdone
and yet while apparently willing to tell every-
thing, they may continually evade answering
straightforward questions.

A careful history and thorough examination
with laboratory procedures as indicated are al-
ways necessary. The character of the skin le-

186

Jour. M.S.M.S.

SELF-INFLICTED INJURIES— HART

sions produced by escharotics has been so often
described that it need not be repeated here.
Biopsy, culture, or curettage of the lesions may
I at times be necessary. When these patients
cannot be kept under continuous observation,
suggestions as to the appropriate location of
new lesions followed by their appearance may
help to clinch the diagnosis.

A word should be said about surgical wounds
which, without obvious cause, will not heal.
These are often most puzzling and the possi-
bility of interference on the part of the patient
should always be kept in mind. The lesion
should be carefully explored, under anesthesia
if necessary, and a search made for sinus tracts,

I foreign bodies, or any other condition which
1 might keep the wound open. A dressing should
be applied which will prevent the patient from
reaching the area involved. For this purpose
a plaster cast is ideal. Often painting the skin
in the region of the wound with one of the dyes
such as gentian violet or mercurochrome will
leave tell-tale marks on the fingers should the
; patient attempt to reach the area. A window
i can be cut in the plaster cast for dressings pro-
1 vided it is closed after each dressing in such
i a manner as to prevent the patient from tamper-
I ing with the wound. It may be either sealed
i with collodion or plaster-of-Paris or strapped
with adhesive in a pattern which the patient
1 cannot duplicate. Not infrequently the patients
I complain bitterly against the application of a
i cast and use every artifice to have it removed.

Daily inspection of the wounds will show a
rapidity of healing that is surprising. Certain
patients, when they realize that their actions
are understood and see that the wound is going
! to heal, are able to adapt themselves to the idea
of permanent recovery. Others will quickly pass
from the care of the physician who has detected
their actions and their lesions will again appear.
Many of them may be satisfactorily treated only
by an experienced psychiatrist.

Treatment

The physician is usually faced with the prob-
lem of getting the lesion healed as a proof of
his diagnosis before he can mention his suspi-
cions either to the patient or to the patient’s
family. One can never expect cooperation from
the patient while the lesions are present. After
the physician has proved his diagnosis by the

healing results obtained, the patient may be
placed on good behavior by a promise to with-
hold the diagnosis from his family so long as
he remains well.

It is essential both for diagnosis and for treat-
ment that these patients be placed under close
supervision and that the doctor be given absolute
authority to apply any type of dressing he may
think necessary. In the case of patients who
fall in Groups 1 and 2 the lesions can be easily
cured if the patients are kept under close obser-
vation. Material which might be used to cause
the lesion should not be available and the body
area involved should be made inaccessible by an
occlusive dressing. After healing is complete
recurrent lesions can frequently be avoided by
holding over the patient the threat of exposure.
This does not have to be expressed in words
which the doctor might find it difficult to prove,
for the patient quickly learns that the nature
of his condition is understood. They can be
told that their case will be fully explained to
their family doctor, who will be instructed to
return them immediately if further lesions de-
velop.

It is doubtful whether the patients who fall in
Group 3 can be cured and they should certainly
be placed under psychiatric treatment. It is also
very difficult to get them to admit the motive
behind their actions. They are probably closely
related to the group of masochists.

The patients in Groups 4 and 5 are primarily
ps}^chiatric problems and surgery should only
be supplementary to the treatment of the major
conditions.

Prognosis

In Groups 1 and 2 the local lesion can be
cured in all cases and in a high percentage re-
currence can be avoided.

In Group 3, the lesion can be healed, but
it is doubtful whether these patients can be per-
manently cured.

In Groups 4 and 5, the local lesion can be
healed, but permanent recovery depends on the
nature of the underlying psychiatric condition.

In conclusion I should like to make two quo-
tations, the first from M. Dieulafoy :*

“When one goes to the depths of the mental state
of these pathornimes, in whose case the goal or aim

*Report of Case of Self-Inflicted Lesions. Bulletin de
L’Academie de Medecine, Vol. 1, 1908.

March, 1941

187

SELF-INFLICTED INJURIES— HART

is not fraud, nor money, nor desire for gain, one is
greatly at a loss to find an explanation for this mental
state. Thus, here is a young girl who has made
these ulcers for two years until they have disfigured
her, and one cannot find a reason which will account
for her acts. The girl whose history I have given
made these ulcerations on her legs and allowed them
to amputate her thigh and continued to make them
with the idea that it might be necessary one day to
have a new amputation.

“Our man allowed them to cut off his arm without
divulging his secret when he would have had to say
only a word to stop the surgeon’s knife. And our
man is not crazy, nor is he a degenerate, nor is he
an alcoholic ; he is not a neurasthenic, he is not even
hysterical, there is no evidence of an hereditary taint,
he is intelligent and well raised ; at the insurance com-
pany where he is employed each person sings his
praises, and, in the numerous conversations we have
had with him, we have found him dignified and in-
telligent. Then, how can one explain this strange
aberration which for two and a half years has in-
cited this man to cover himself with ulcers and let
them amputate his arm? He told us, T was driven
to make my lesions just as a morphine addict is driven
to the injection of morphine.’

“The comparison is not exact, for in the case of
the morphine addict the injections of morphine are
followed by pleasure and satisfaction, while the ulcers
of our man give him only torture and pain. And
then, his consenting to having his arm amputated —
how can one explain that?

“The pathomimes of this category do not receive
from their acts any profit or any good, but they
experience a peculiar pleasure in making themselves
a problem and in their complaints they get a great
satisfaction out of mystifying their fellow-creatures.
They have no confidants, they guard their secret with
jealous care as a miser guards his treasures, and
after a while, habituated to this unpleasant deception,
they become accustomed to it and they cannot leave
it of their own volition or free will.

“The deeds of this type of individual may well trou-
ble the conscience of the legal physician. In the im-
pulsive act which our man has committed, can one
admit that he was responsible? No! He is not re-
sponsible in the least. Thus we told him after his
mental state had been cured that for two years and
a half he had obeyed a fixed idea, ‘like a machine,
without knowing why.’ ’’

I will not attempt to go into a discussion of
the psychiatric problem of these cases, but I
should like to quote from Karl A. Menninger:*

“The chief elements in malingering of the self-
mutilative type are: the infliction of a wound on the
self which results in pain and loss of tissue ; exhibi-
tion of the wound to persons who react emotionally

•Psychology of a Certain Type of Malingering. Arch. Neurol,
and Psych., Vol. 33, 1935.

to it and give sympathy, attention and efforts to cause 1
healing; the deception of the observer as to the origin 1
of the wound and often distinct efforts to defeat thera- .
peutic measures and the obtaining of monetary or other '
material reward, or detection, exposure, with constant
humiliation, reproach and sometimes actual punish- I
ment. ... *

“The well-known disparity between the great suffer- {
ing voluntarily endured and the objective gain is to J
be explained on two bases : first, that the gain is only i
partly represented by the monetary reward, but in- ]
eludes also the satisfactions in exciting sympathy, at- 1
tention, perplexity and dismay, and, second, the pain j
is not only incident to the device used for obtaining |
the gains, but is psychologically demanded by the con- i
science as a price for indulging in them. Actions speak i|
louder than words, and it is clear that however con- ^
scienceless the malingerer appears (or claims) to i
be, he unconsciously feels guilty and inflicts his own '
punishment.’’ |

His conclusions are as follows : |

“Malingering, therefore, of the self-mutilative type |
may be described as a form of localized self-destruc- i
tion which serves simultaneously as an externally di- |
rected aggression of deceit, robbery, and false appeal. \
The aggression is of such an inflammatory sort that
it, in turn, obtains for the malingerer not only s\Tn- ■
pathy, attention and monetary gain (at first), but, ’
ultimately, exposure, reproach and ‘punishment.’ Both
aspects of the induced treatment by the outside world ,
are strongly tinctured with the perverted erotic sat-
isfaction incident to masochism and exhibitionism.

“From this, one may conclude that the original act
of malingering of this type serves chiefly as a provoca-
tive aggression; that is, it is a minor self-attack
designed to excite a major attack (both indulgent and
punitive) from other persons, the pain involved being
the price demanded by the conscience for the uncon-
scious satisfactions achieved.’’

CONSERVING VISION

You have undoubtedly noticed that your
JOURNAL is now printed on tinted paper.
While certain of the publishing companies,
notably The C. V. Mosby Company of Saint
Louis, have used this tinted paper for books,
this is the only state journal which has taken
this step to help conserve the eyesight of its
readers.

Any comment, whether you approve or dis-
approve, would be gratefully received.

188

Jour. M.S.M.S.

SEPTIC BRANCHIAL CYST— BERGE

' I
1 1

j Septic Branchial Cyst

Eradication by Electrical
Cauterization
(Report of a Case)

By Clarence A. Berge, M.D.

Detroit, Michigan

Clarence A. Berge, M.D.

' M.D., University of Michigan, 1917. For-

mer Attending Specialist in Orthopedics, U. S.
i Veterans Administration, Detroit. Auxiliary

physician and surgeon. The Grace Hospital,

Detroit. Member^ Wayne County Medical
Society and Michigan State Medical Society.

,1

j ■ A BRANCHIAL cyst IS an embryonic remnant in
I the neck which produces unsightly deformity
i when distended. Repeated tappings for drainage,
ap"lied for cosmetic reasons, very often cause
infection, and in this event the cyst becomes a
potent focus of infection which produces consti-
tutional symptoms.

A septic cyst produces a disabling factor sim-
ilar to that of a diseased tonsil, and similarly to
a tonsil the treatment of choice becomes the re-
moval or destruction of the same.

The case reported is that of Mrs. M. S., aged thirty
j years when her cyst was eradicated September 12, 1938.
i Her first symptom was a swelling on the left side of
I her neck making its appearance at the age of fourteen.

At first there were no symptoms at all aside from an
i ugly deformity. Between the year 1923 and the year
i 1937 this swelling was drained by tapping twenty-nine
times. The cyst would remain small for a time after
each drainage, but would progressively distend sufficient-
! ly during each six months to make her desire another

I tap.

In 1937 she came to the author to have her cyst
drained as had been the routine previously.

! . Past History. — Her history showed that she had felt
I increasingly tired, regardless of exertion, almost contin-
I ually since 1928, five years after the routine tapping of
the cyst had been started.

j Physical Examination. — Examination revealed a tem-
j perature of 99.0°F. Her physique was normally slender
I with mild malnutrition. Her appetite was usually good.
Her tonsils had already been removed very cleanly and
there was no evidence of dental sepsis. Chest, ab-
dominal, and urinary findings were negative. She
seemed a very nervous, introverted person keenly con-
scious of the ugly deformity in her neck. This was
a fluctuant saccular tumor the size of a Bartlett pear
protruding in front of the sternocleidomastoid muscle
on the left. This enlargement showed no redness or
heat, and was only slightly painful to pressure.

Diagnosis. — It was plainly apparent that she was suf-
March, 1941

fering from low grade septic intoxication even though
evidence of any fulminating infection was absent. The
patient agreed that the infected contents of the cyst
seemed causative of her constant tired feeling. A num-
ber of medical examinations revealed nothing wrong
aside from the cyst.

Procedures. — The cyst was drained under novocain
anesthesia and thirty cubic centimeters of creamy se-
cretion which contained thickened fibrinous particles
was exuded. A considerable enlargement was still pal-
pable and it was apparent that not more than two-thirds
of the cyst cavity had been evacuated. The patient was
satisfied for the time and stated that this was as ex-
tensively as the cyst had been drained subsequent to the
year 1928.

The cyst was drained again six months later and at
this time the temperature was 99.4°F. and the patient
said there had been no remission of her constant tired
feeling. She was plainly very much discouraged.

Discussion of Operative Methods

Eradication of the cyst was definitely indicated
by this time. Formal excision of the cyst was
considered ; a most formidable surgical procedure
requiring a large incision with dissection at the
outer border of the cyst wall progressing inward
from the sternocleidomastoid border to the
posterior tonsillar pillar, passing through amid
the great vessels and entailing the risk of cut-
ting the laryngeal innervation and injuring the
patient’s voice.

The sclerosing method as described by Cutler
and Zollinger was considered. In this case the
drawback to using sclerosing was to evacuate the
cyst completely of thick fibrinous material
through any opening small enough to practically
retain the sclerosing solution. Sclerosing could
not be successful if thickened exudate prevented
contact of the solution with the cyst wall and
all contents remaining in would still be septic
media. - Elimination of the focus of infection
was the most important thing and this could not
be assured by sclerosing even though the deform-
ity might be lessened visually.

It was decided to abandon the idea of formal
surgical cyst excision and to only use the scleros-
ing treatment in case a certain method of thermal
dissection of the cyst wall should prove unsuc-
cessful : and as this method was successful, scle-
rosis was never attempted.

This thermal dissection is accomplished by the
cautery. The writer has first used this method
in removing Bartholin cysts and had found it
satisfactory. It consists of opening the cyst

189

SEPTIC BRANCHIAL CYST— BERGE

widely and then, while holding the wall edges
under traction so they will flare apart, destroying
the cyst wall tissue from the bottom out with the
electrical cautery. There is, of course, a certain
amount of sloughing discharge for some days

Fig. 1. Cyst as distended originally.

after the cautery application but this is minor and
inconsequential. As far as ultimate results go
it makes no difference whether the dissection of
the cyst wall is thermal from the inside or is
performed with a sharp scalpel from the outside.

Operation. — On September 12, 1938, thermal dissection
of Mrs. S.’s branchial cyst was performed (Fig. 1).

Pre-operative medication consisted of ten grains of
sodium barbital given by mouth one-half hour before
the operation started. This was for protection against
a possible novocain or cocain poisoning.

Skin and fascia were infiltrated with two per cent
novocain and a one and one-half inch incision was made
vertically over where the cyst was bulging the most
anterior to the sternocleidomastoid border. This was
made elliptical to cut out the old tapping scars. The
protruding cyst was dissected bluntly until enough of
it was exposed to permit making an opening in it of
the same length as the skin incision and parallel with
same. It was not necessary to go in deeply as the
cyst wall became more and more adherent to adjacent
tissues as separation progressed and the operator would
have been forced to use the sharp knife edge if he had
dissected further. The cyst was then opened to a length
of one and one-half inches and forty cubic centimeters
of creamy contents evacuated. The cyst wall was
flared out on four sides and under traction the cyst
resolved itself into a deep funnel-like cavity containing
much mucoid substance and fibrin which had a mild
putrefactive odor. This material was easily wiped away
and the clean interior wall exposed. A gauge pledget
saturated with two per cent cocain was placed within

the cavity, packed down well to the bottom, and left in
place for two minutes. The patient at this time was
asked to speak during the time the cautery was applied
in order that any difficulty in phonation might be ac-
cepted as evidence that burning was extending too deep-
ly toward the laryngeal region (Fig. 2).

The large round applicator of the Post cautery was
applied to the cyst wall from the bottom outward, going
clockwise around and around until the terminal edge
was reached. The actual time of application of the
cautery was about one minute for the entire area.

No hemorrhage was encountered. A rubber wick
drain was placed in the seared cavity and skin and fascia
were closed above this drain with two horsehair sutures.
An ordinary small dressing of gauze and adhesive tape
was applied.

There was no real pain at any time, but the hissing
and scent of the cauterizing frightened the patient
greatly for the moment. She left the table unassisted
and walked from the office.

Postoperative History. — Convalescence was unevent-
ful. The rubber wick drain was kept in for fourteen
days and the drainage was serous and very moderate.
Removal of the drain permitted the incision to close
promptly and at this time there was still some pal-
pable swelling in the neck, about one-fourth of the
total volume present originally. October 7, 1938, the
twenty-fifth day, the incision ruptured spontaneously
and drained for three days. From that time on the
incision remained closed and there was gradual regres-
sion of the necrosed cyst remnants until all evidence
of the cyst had disappeared by January 1, 1939. There

190

Jour. M.S.M.S.

CANCER OF THE CERVIX— TODD

was only slight discomfort during convalescence, which
was ambulatory.

September 15, 1939, her temperature was 98.6°F. She
did not regain a feeling of well being until after she
was delivered of a living child May 17, 1939. The
pregnancy undoubtedly levied its own toll upon her
and the effect of eradication of the septic cyst could
more truly be evaluated since the birth of the baby.
Since that time she has felt well and strong and
has possessed normal energy such as she did prior to
the year 1928.

Summary

A focus of infection was eradicated.

A cosmetic deformity was removed by an
office procedure performed at reasonable expense
leaving a negligible scar.

The personality change was particularly out-
standing.

References

1. Cutler, E. C., and Zollinger, R. ; Am. Jour. Surg., n.s.,
19:411, 1933.

2. Martin, E. G.: Jour. A.M.A., 99:268, 1932.

Cancer of the Cervix*

Time Wasted

By Oliver E. Todd, B.S., M.D.

Toledo, Ohio

Oliver E. Todd, M.D.

B.S., University of Michigan, 1932. M.D.,

University of Michigan, 1934. Attending
physician at Toledo Hospital in Obstetrics and
Gynecology. Junior Obstetrical Staff at Lucas
County Hospital.

■ This study was motivated by a desire to de-
termine whether the factors mentioned by
Miller^ and Collins^ were responsible for the de-
lay seen among similar patients in the Depart-
ments of Obstetrics and Gynecology at the Uni-
versity of Michigan, and also, to note if possible,
how much if any improvement has occurred in
recent years. It was desired to devise some meth-
od of handling the problem so that patients might
receive treatment earlier in the course of the
disease.

This study covers a period of six years (July
1, 1931, to July 1, 1937) and includes the records
of 634 consecutive patients with cancer of the
cervix. All of these patients were seen and

*From the Department of Obstetrics and Gynecology, Uni-
versity of Michigan Hospital, Ann Arbor, Michigan.

studied in the Gynecological Cancer Conference
at the University of Michigan. One hundred
per cent follow-up has been maintained since the
origin of this conference in 1931. The informa-
tion used in this study was obtained from careful
review of the Conference records.

Clinical Classification. — All cases were grouped
according to the clinical classification developed
by and used at the University of Michigan. This
system of clinical grouping has been continu-
ously and successful!)^ used by us since our can-
cer conference started in 1931 and is elsewhere
fully described by Miller and Folsome.®

Ages. — The average age of the 634 cases was
forty-seven years. The youngest patient in our
study was twenty and the oldest seventy-nine
years of age. Three hundred and fifty (55 per
cent) were premenopausal while two hundred
and eighty-one (44 per cent) were postmeno-
pausal at the time of the onset of symptoms. In
only three instances was the information so
incomplete as to make it impossible to place them
in one of the two groups listed below. Patients
classified as postmenopausal were (1) Those in
whom menstruation had ceased, or (2) patients
having very infrequent periods associated with
vasomotor disturbances, and finally, (3) all cases
over fifty-five years of age.

Parity. — Approximately 13 per cent of the pa-
tients were nulliparas but of these 18 had one
or more abortions. Among the remaining 87
per cent there were twelve cases for which the
parity was not stated (Table I). This may be
said to conform with the usually accepted rela-
tionship between cancer of the cervix and parity.
The average number of children among the
parous women was 4.1 per patient.

TABLE I.

PARITY

Nullipara

Number

81

Per cent
12.78

Multipara

541

85.33

Not stated

12

1.89

Average number of children (multipara) 4, 1

Education. — Many educational programs have
been carried on attempting to combat the inroads
of cancer and bring the patient to physicians
while the neoplasm is still early. This study
would seem to demonstrate that effort in this

M.4RCH, 1941

191

CANCER OF THE CERVIX— TODD

direction has been of little value. As shown in
Table II, there has occurred no significant change
in the relative incidence of the various clinical
groups admitted to the hospital over a period of

even been examined. Since most of these cases
were well advanced when medical attention was
first sought, this is not a very commendable
showing. Since bleeding or spotting occurring

TABLE II. CLINICAL GROUPING

7-1-31 to 7-1-37

Clinical
Classification
on Admittance

Year

of Admittance

Before

7-1-31

7-1-31

to

7-1-32

7-1-32

to

7-1-33

7-1-33

to

7-1-34

7-1-34

to

7-1-35

7-1-35

to

7-1-36

7-1-36

to

7-1-37

Total

Cancer of Cervix I

4

4

2

7

2

1

5

25

Cancer of Cervix II

7

6

12

5

14

15

11

70

Cancer of Cervix III

19

28

14

34

26

39

16

176

Cancer of Cervix IVA

19

31

46

50

45

39

47

277

Cancer of Cervix IVB

1

9

8

13

14

12

19

76

Cancer of Cervix I VC

1

2

3

0

2

0

2

10

Total Cancer of Cervix

51

80

85

109

103

106

100

634

six years (1931 to 1937). The great majority
of cases are still far advanced (Clinical Group
IV) when they come under observation.

Initial Symptom. — The majority of patients
first sought medital advice because of abnor-
mal bleeding. This so-called “spotting” was
generally characterized by the fact that it
was (1) intermenstrual, (2) progressive, (3)
prone to follow trauma such as coitus, douch-
ing, exercise, et cetera, and (4) it was painless.
This coincides with the findings of other ob-
servers who have repeatedly stated that ab-
normal bleeding or spotting is one of the most
significant and consistent early symptoms in
cancer of the cervix. Most patients also com-
plained of a gradually increasing foul dis-
charge which must also be considered a sig-
nificant, though generally late symptom.

Entrance Diagnosis

Inspection of Chart I reveals that of the 506
cases with available information, 383 cases or
75.7 per cent entered the University Hospital
with the diagnosis already made. Miller in his
earlier study reported this figure to be 56 per
cent and Collins found 77 per cent. One hundred
and twenty-three cases or 24.3 per cent had not
been diagnosed and of these 42 cases had not

Diagnosis before Admittance

Mo.

Perceni

Diagnosed

083

75.7

Not

Diagnosed

123

24.3

_

Not

Examined

42

.

History

Indefinite

128

Chart I.

after the menopause is likely to be particularly
significant, a comparable analysis was made for
both the pre- and postmenopausal groups as
indicated in Charts II and III. Interestinglv
enough the number diagnosed and not diagnosed
remains approximately the same in the two
groups. Again referring to the studies pre-
viously mentioned, the number diagnosed among
the postmenopausal group in Miller’s original
series was 64 per cent while Collins found 82
per cent diagnosed in the postmenopausal group
in his follow-up study. If the physician would
consider every case of postmenopausal bleeding
cancerous in origin, at least until proved other-

192

Tour. M.S.M.S.

CANCER OF THE CERVIX— TODD

: wise, the comparison between the pre- and post-
I menopausal groups would in all probability re-
; veal a better diagnostic incidence for the latter
; group than is here reported. In most cases biop-

Dia$nosis Before Admittance

First Symptom Before Menopause (350)

‘ cases

No.

%

Definite

Diagnosis

225

76.

Not

Diagnosed

71

24.

.

Not

Examined

20

.

History-

Indefinite

54

Chart II.

sy material can be easily obtained in the office
with a Gaylor or punch biopsy forceps and the
tissue sent to a competent pathologist for diag-
nosis. Then, if doubt still exists as to the pres-
ence of cancer, additional tissue should be ob-
tained for microscopic study. A few unnecessary
operations of this type are certainly preferable
to a single missed diagnosis. Postmenopausal
patients with bleeding should alw'ays be thorough-
ly investigated.

N on- examination. — The fact that forty-two
cases had not had a pelvic examination prior
to admittance for treatment is indicative of a
tendency which warrants criticism. The me-
dieval idea that bleeding woman is unclean
and should not be examined should be dis-
carded.

Also oxytocic drugs, useful enough in their
place, should not be used to control bleeding with-
out accompanying adequate investigation as to
the source of bleeding. Too often such therapy
is continued until the physician recognizes that
the patient is not improving and examines her,
or, the patient becomes dissatisfied and seeks
medical attention elsewhere. Such practice may
lead to the loss of much valuable time. Patients
with abnormal bleeding should not be permitted
to go unexamined for any considerable length of
time. A patient who consults a physician with
the complaint of abnormal bleeding does so be-
cause she is concerned and postponement of the
examination is not justifiable.

Time Lost by Patient. — Table III shows the
average elapsed time from the appearance of
the first symptom (spotting) to the first exam-
ination and the average elapsed time from the

Diagnosis Before Admittance
First Symptom After Menopause (261 cases)

No.

To

Definite

Diagnosis

155

74.85

Not

Diagnosed

52

25.12

.

Not

Examined

22

.

History-

Indefinite

74

Chart III.

TABLE III. TIME WASTED

Days

Weeks

Months

Time

Wasted

(Months)

Average time interval
from first symptom
to first examination.

178.

25.48

6.4

6.4

Average time interval
from first examination
to first treatment.

32.

4.62

1.1

1.1

Average total time wasted 7 . 5 months

first examination to the first treatment. The
average time wasted for all cases from the ap-
pearance of the first symptom to the institution
of therapy was 7.5 months. Approximately 6.4
months of this time waste may be attributed to
the patient chiefly because of her failure to s6ek
medical attention. Examination of records of
patients having had their first examination else-
where shows that, in this group, there was a
delay of 7.4 months between the first symptom
and the commencement of treatment, of which
six months could be attributed to the patient
for the reason mentioned above. Delay after
examination may be due to failure on the part
of the physician to recognize the disease, or if
recognized, failure to properly impress upon
the patient the importance of immediate therapy.
It is our feeling that at least a part of this delay
may be attributed to time required for mak-
ing financial arrangements, necessary for treat-
ment. In many instances it was necessary for

March, 1941

193

CANCER OF THE CERVIX— TODD

TABLE IV. AVERAGE DURATION OF SYMPTOMS BE-
FORE THERAPY STARTED AT THE
U. OF M. HOSPITAL

Admittance

clinical

classification

Number

of

cases

Average duration
of symptoms in
- weeks before
therapy started

I

24

12.7

II

66

18.7

III

162

28.7

IVA

269

31.9

IVB

65

38.7

IVC

6

49.5

the patient to return home, or if at home, to apply
for financial aid through the local agencies be-
fore treatment could be started. We believe
that this may have accounted, in part at least,
for the loss of time attributed to the physician.

Time Lost by Physician. — In our study the
time wasted by the physician (Table III) is con-
siderably less than the six months reported by
Miller in 1933. Interestingly enough the aver-
age time from the first symptom to the first ex-
amination in his series was 6.2 months, about the
same as observed by us. In the follow-up re-
port by Collins there was a time loss from
the first symptom to the first examination of
seven months and a time loss of 2.25 months
from the first examination to the first treatment.
Assuming that the Michigan and Iowa physicians
are equally capable it appears that the recent
educational programs have focused the atten-
tion of the average physician upon the close cor-
relation between abnormal bleeding and cancer
but have failed to impress the lay mind to any
degree. Apparently most physicians are alert
and are making every effort to detect the pres-
ence of cancer. ’ How great an influence the
few physicians who fail to keep up with modern
trends influence these figures, is, of course, diffi-
cult to determine. According to a report of the
Cancer Commission of the Pennsylvania State
Medical Society^ may years ago it was estimated
that 10 per cent of the physicians, usually those
who failed to attend medical meetings and who
seldom read medical journals, were responsible
for 90 per cent of the time waste attributed to

TABLE V. CORRELATION BETWEEN SURVIVAL RATE
AND DURATION OF SYMPTOMS PRIOR
TO TREATMENT

Duration

of

symptoms

in

months

5-year

Group

No. of
cases

.%

living

7-1-37

CO

1

o

15

53.3

CO

1

05

24

29.2

6-9

13

30.8

9-12

7

28.6

12-15

14

42.9

15-18

1

100.0

18-21

1

00.0

21-24

24 & over

1

00.0

physicians. We found that in those cases having
their first examination at the University Hospi-
tal there was an average time loss of eleven
days attributable to the staff. This delay is time
required to secure state or county orders to
cover the costs of hospitalization and treatment.
This same factor, as already indicated, must be
considered in the group having their first exam-
ination elsewhere.

An average of 7.5 months for all cases from
the onset of the first symptom to the institu-
tion of therapy should constitute a challenge to
every practicing physician and every organiza-
tion having lay education regarding cancer as
its objective.

Table IV shows the average duration of symp-
toms in weeks before the institution of therapy
for the different clinical groups or classifications
— i.e. the extent of the disease on admittance.
As the average duration of symptoms before
the institution of therapy progressively increases
the clinical grouping naturally advances. While
this is what may be normally expected, this
does not represent the true picture for all cases.
Intelligent patients with symptoms of only a few
weeks’ duration have been seen with carcino-
matous involvement so extensive as to render
the prognosis hopeless from the start. The cor-

194

Tour. M.S.M.S.

CANCER OF THE CERVIX— TODD

ollarv is also true for individuals have been seen
with relatively early lesions but with prolonged
symptoms extending over many months.

of symptoms before therapy was started in our
grade IV- A cases) the prognosis is zero, (Chart
IV). Miller previously reported this percent-
age decrease in chances for cure as 20 per cent
per month. Reconsideration of Table III in

Month's Duration From First Symptom

Chart IV.

Adjustments. — In Table V an attempt has been
made to correlate survival rate and duration of
symptoms prior to treatment. The fact that
there were some patients who had symptoms
more than a year before treatment was started
and have survived five years suggests that in
some cases at least there is not the close cor-
relation between the extent of the disease and
the duration of symptoms as suggested in Table
IV.

Again referring to Table IV, if it is assumed
that in the clinical grade IV cases (with para-
metrial extension) that the disease is beyond
hope of cure then the chance for cure decreases
3.34 per cent per week or approximately 15 per
cent per month. This figure is arrived at by
plotting the duration of symptoms against the
chance for cure. It is assumed that in the ab-
sence of symptoms the chance for cure would
be one hundred per cent. When there have been
symptoms for 31.9 weeks (the average duration

inasmuch as the average duration of symptoms
in all cases before the institution of the therapy
is 7.5 months.

Immediate Diagnosis Chart V shows

the percentage of cases diagnosed by the local
physicians at the time of the first consultation
with relation to the duration of symptoms. Ob-
viously as the duration of symptoms before
medical attention increases the percentage of
cases diagnosed also rises. The fact that some
cases do not have symptoms early in the course
of the disease is important. In this series there
are 26 clinical group IV- A cases in whom diag-
nosis was made and treatment commenced with-
in six weeks of the appearance of the first symp-
tom. In a number of these cases the diagnosis
was made in the absence of symptoms during
the course of routine investigation for other
complaints. Clearly lay educational programs
must do more than emphasize the importance of

March, 1941

195

CANCER OF THE CERVIX— TODD

1

abnormal bleeding; they must also educate women the patient to seek medical attention,

to seek periodic pelvic examination, particularly 5. In this series the chance for cure decreased
after the thirty-fifth year. at the rate of approximately fifteen per

Percent Diagnosed in Relation to
duration of symptoms

Diagnosed

Chart V.

Conclusions

1. The chief symptoms of cervical cancer are
abnormal bleeding and offensive discharge.
This abnormal bleeding is usuaHy charac-
terized by the fact that it is intermenstru-
al, progressive, prone to follow trauma and
is painless.

2. The longer the duration of these symptoms
the more advanced the disease is likely
to be.

3. The average time lost from the appearance
. of the first symptom to the institution of

therapy in this series is 7.5 months.

4. Most of the time lost before treatment can
be attributed to a failure on the part of

cent per month after the ^ appearance of
the first symptom.

6. If the reports of earlier observers, notably
Miller and Collins, can be compared with
our observation, and we believe they can,
then it appears that the time waste attribut-
able to physicians has materially decreased.

7. Women must be educated to seek periodic
medical examination if early therapy is to
become more than a cherished hope.

Bibliography

1. Collins. R. M. : Additional data on uterine cancer. Jour.
Iowa State MeT Soc., 24:71-75, (February! 1934.

2. Miller, N. F. : Some data on uterine cancer. Jour. Iowa
State Med. Soc., 23:132-135, (March! 1933.

3. Miller, N. F., and Folsome, C. E. : Carcinoma of the
cervix. Am. Jour. Obstet. and Gynec., 36:545-561, (October)
1938.

4. Quoted by Miller. -

196

Jour. M.S.M.S.

MONILIASIS— VAN BREE

Moniliasis

Sulfapyridine Treatment

By Raymond S. Van Bree, M.D.

Grand Rapids, Michigan

R. S. Van Bree, M.D.

M.D., University of Michigan Medical School,

1929. Member, Attending Surgical Staff St.

Mary’s Hospital. Member of the Michigan
State Medical Society.

■ While monilia are recognized as the cause of
various pathological conditions, there are rela-
tively few reports in the literature in which the
etiology is clearly established. This is particular-
ly true of lesions other than dermatologic. This
report concerns a case of gastro-intestinal and
pulmonary moniliasis, in which the diagnosis
was confirmed by laboratory findings and in
which sulfapyridine was used for treatment.

Case History

The patient was first seen Tune 25, 1937, complain-
ing of acute distention and marked spastic pain in the
abdomen and a slight neuritis involving the right shoul-
der.

He stated he had been having these gastro-intestinal
attacks off and on for the past twenty years, and
they had gradually increased in intensity and dura-
tion. During the last year of the world war, he was
gassed with mustard gas, and at that time almost died.
Shortly thereafter he was discharged from the army
with the following diagnosis : “1. Tuberculosis, pul-

monary chronic, active, moderately advanced. 2. Chron-
ic Bronchitis. Prognosis : Favorable.”

He was placed under treatment in an army hospital
for several years. Attacks of pain in the abdomen
started at about that time and distention began making
its appearance in about 1934. They were usually more
severe at night. At the onset of one of these attacks,
a severe distension of the abdomen would appear with-
in fifteen minutes to one-half hour and continue for a
period of twenty-four hours to one week. Neuritic
pains in the right shoulder appeared two or three
times during recent attacks.

Past History. — The patient had never to his knowl-
edge had a skin disease. Several times tuberculous
adhesions in the abdomen had been suspected and op-
erations suggested. In June, 1937, a diagnosis was
made by a reputable neurologist of “Post-influenzal
radiculitis and inflammation of abdominal sympathetics.”

Physical Examination. — On examination, patient was
a well-nourished male, weighing approximately 145
pounds, medium height, dark skinned, aged forty-nine.
Temperature, pulse and respirations normal. Eyes, ears,
nose and throat negative. Chest negative, lung fields

clear and resonant, heart sounds normal, abdomen
acutely distended. No particular points of tenderness
were elicited. On auscultation, intestinal action could
be heard. The rest of the examination was negative,
except for slight tenderness over circumflex nerve.

Fig. 1.

Progress. — Patient was treated empirically with in-
travenous sodium salicylate and the acute attack sub-
sided in about three days ; the neuritis did not return.
This method of treatment was continued until Sep-
tember 17, 1939, with attacks reoccurring approxi-
mately every two or four weeks. Results of above
treatment were indifferent.

During the month of September, 1939, the attacks
of pain and distention gradually increased in fre-
quency and violence until they merged into one con-
tinuous attack. On September 17, 1939, the patient
was apparently suffering from an upper respiratory in-
fection and pneumonia was suspected. He consented
to hospitalization at this date. Previous to this he
had made periodic trips to government hospitals for
observations but always returned with no definite diag-
nosis.

Laboratory Examination. — X-ray reports on the chest
on September 17, 1939, were negative. Report on the
abdomen was as follows ; “Non-rotation of the colon
considered a congenital anomaly. Generalized slowing
up in passage of barium through the small bowel, the
exact etiology of which is not determined. No organic
pathology to account for the slowing is observed and
may be incident to the congenital anomaly although
this is thought unlikely. No obvious bowel obstruction
is demonstrated in these films.” The Kahn test was
negative, urine negative, except for slight traces of
albumin and occasional pus cell. No tubercle bacilli
were found in feces or sputum. No pneumococci were
found in sputum.

Eurther Progress. — The attack gradually subsided
sufficiently so that the patient decided to go home on
September 25, 1939. Shortly after he returned home,
distention and pain again increased in severity and

P7

March, 1941

MONILIASIS— VAN BREE

became continuous. Upon his complaint that the right
side of his throat often felt scratchy during these at-
tacks, a throat culture was taken and sent to the
Michigan Department of Health Laboratory, which
reported “Fungi resembling monilia were found.” Sub-

merging into each other and continuing to January
1, 1940.

Treatment — On January 1, 1940, the patient suffered
a relapse, with pain in the chest, and 103° tempera-
ture rectally. On January 2, 60 grs. of sulfapyridine

Fig. 2. Fig. 3. Fig. 4.

sequently, the cultures were studied further and ac-
cepted to be monilia. Death was produced in a rabbit
by injection of the cultures, the organisms were re-
covered and the histologic picture found compatible
with an infection with pathogenic fungi. Monilia were
also found in the sputum and stool but not in the
urine of the patient.

After the patient had been treated with gentian violet
applications to the throat for ten days, gall-bladder
drainage was done and monilia were isolated from the
bile. An antigen was made from a killed fungus cul-
ture and both scratch and intradermal tests were made.
There were only moderate local reactions, but in both
instances the severity of the abdominal symptoms was
noticeably increased for a period of eighteen to twenty-
four hours. On December 18, 1939, a solution of gen-
tian violet was given intravenously. It was afterwards
discovered that the solution had been made up to
3 per cent instead of 1 per cent. After 8 c.c. had
been slowly injected the patient complained of moderate
burning in the mid-sternal region. Fourteen hours
later the patient was sent into the hospital.

On admittance, the patient had marked dyspnea and
pain in the chest. Temperture was 102.6° and remained
around 101° for the next five days. Coarse rales
were heard over both lung bases, extending up to
the nipple on both sides. Slight dullness was found a
little later on the left side between the fourth and
seventh ribs with increased breath sound over this
area. The white blood count was 15,000 with 77 per
cent polymorphonuclears, 17 per cent large lympho-
cytes, 4 per cent lymphocytes, and 2 per cent transi-
tionals. Sputum examination, on entrance, showed a
few pneumococci which did not react to diagnostic
serum mixtures, a, b, c, d, e, or f. Patient remained
almost continuously in the oxygen tent for ten days,
pain in the chest, and dyspnea gradually subsiding.
Temperature gradually subsided from 102.6° to normal
in six days. During the first thirteen days, the patient
had moderately severe attacks of distention and pain

was given during a period of twenty-four hours. X-ray
of this date shows pneumonic consolidation of left lung-
with clearing up in its central portion, showing evi-
dence of beginning resolution. White blood count was
43,200 with 93 per cent polymorphonuclear. Sulpha-
pyridine was reduced on January" 3 to 40 grs. and
temperature became normal on January 4, with a daily
afternoon rise to 101° until January 7. Sputum
examination showed no pneumococci at the height of
the fever. Temperature stayed normal thereafter and
patient was remarkably free from pulmonary symp-
toms. During this period, a dose of 40 grs. of sulfa-
pyridine was given daily. On January 10 it was re-
duced to 30 grs.; on January 13, to 20 grs.; and on.
January 15 to 7^ grs. The patient continued on 7W
grs. sulfapyridine daily until February 3, when the
dosage was increased to 15 grs. daily during an upper
respiratory infection. The drug was discontinued on.
February 9.

During the use of the sulfapyridine the patient
did not have any pain or distention except for one
moderate attack lasting twelve hours on January 29
immediately following an intradermal test of the monilia
antigen. The local skin reaction for this test was
2 plus for twenty-four hours. The wheal, however,
remained raised and reddened for over two weeks.

After the temperature became normal on January
7 the patient raised a small amount of mucopurulent
sputum each day, at first blood-tinged. The report
of x-ray taken on January 16 was “Delayed resolution
in pneumonic consolidation in lower left lobe. The
possibility of tuberculosis should, we believe, be con-
sidered in these cases. We suggest sputum examina-
tion.” This observation was interesting in view of
the fact that Stovall and Greeley have stated that pul-
monary moniliasis in “the severe type is much like
tuberculosis and in our experience is often mistaken for
it.” (ref. Stoval and Greeley: Bronchomycosis, Jour.
A.M.A., 91 :1346, [Nov. 3] 1928.) The tuberculin-

test of Mantoux type, 0.1 and 1 mg. proved negative.

198

Jour. M.S.M.S..

SULFAMETHYLTHIAZOL— FINCH, ALPINER AND HUMPHREY

Sputum examination showed no pneumococci or B. tu-
berculosis but continued to show monilia. Whether
monilia was the primary cause of the pneumonic con-
dition or secondary invader on top of irritation caused
by intravenous gentian violet is a question which re-
mains unsettled.

On February 10, the day after sulfapyridine had
been discontinued, specimens of feces and mucopuru-
lent sputum were examined and monilia again found but
in very small numbers. Further x-ray reports showed
continued improvement of pulmonary condition and
patient was sent home on February 14.

On February 15, patient again complained of gas
pains and distention. Sulfapyridine grs. 14 was given
at 7 :30 P.M. and pain and distention quieted down
considerably, improvement being noted for six hours
following administration of the drug. Another IS grs.
was given at 11 A.M. on February 17, and, following
this, pain and distention were entirely gone by 5 P.M.
There was no further attack until February 29 at 3 :30
P.M. At 6:30 P.M. 15 grs. of sulphapyridine were
given and the dose repeated at 11 P.M. By 4 A.M.
the next morning, the pain was gone and by 9 A.M.
the bloating had subsided. The dose of 15 grs. sulfa-
pyridine was repeated at 2 P.M. On April 25, the
patient had another violent attack of distention and
pain starting suddenly at 7 P.M. He was given 15 grs.
sulfapyridine at 8 P.M., 15 grs. at 2 A.M. (April 26)
and 7^ grs. at 7 A.M. By 2 P.M. April 26, all pain
and distention had disappeared. There have been no
further attacks to date. May 31, 1940. An x-ray
examination, March 4, 1940, showed “marked improve-
ment in the pneumonites . . . since last examination.”

Summary

A case has been reported of a patient suffer-
ing from a recent pneumonic condition and pre-
vious gastro-intestinal distress which extended
over approximately 18 years, dating back to a
clinical diagnosis of tuberculosis, unconfirmed.

Monilia were found in throat cultures, bile,
feces and sputum. Pathogenicity was demon-
strated in the rabbit.

There was clinical evidence of amelioration of
symptoms as a result of sulfapyridine therapy.

NATIONAL PHYSICIANS COMMITTEE

As a part of the general program of education and
public enlightenment, the National Physicians Commit-
tee has arranged, through E. Hofer & Sons, to provide
more than 12,000 weekly, bi-weekly and tri-weekly and
foreign language newspapers throughout the United
States with a weekly “Editorial Service.” Practically
every week there is furnished a short, concise article
or editorial dealing with the “medical issue” and stress-
ing the advantages of our system of independent prac-
tice. These more than 12,000 newspapers reach more
than forty million (40,000,000) readers weekly.

Sulfamethylthiazol In
Staphylncoccus Albus
Bacteremia

Secondary to a Carbuncle
of the Nose

By D. L. Finch, M.D.

Augusta, Michigan

in collahoration with

S. Alpiner, M.D., and A. A. Humphrey, M.D.

Battle Creek, Michigan

D. L. Finch, M.D.

M.D., University of Michigan, 1933. Mem-
ber of the Michigan State Medical Society.

Sam Alpiner, M.D.

M.D., Wayne University College of Medi-
cine, 1938. Resident in Leila Y. Post Mont-
gomery Hospital.

Arthur A. Humphrey, M.D.

M.D., Northwestern University Medical
School, 1928. Pathologist, Leila Y. Post Mont-
gomery Hospital, Community Hospital, and
Baitle Creek Sanitarium. Pathological consult-
ant for the Michigan Community Health Proj-
ect. ^ Member of the Michigan State Medical
Society.

■ Sulfamethylthiazol (2 [para-amino-ben-
zene-sulfonamido] 4-methyl-thiazol) , a new
sulfanilamide thiazol derivative, has been dis-
tributed for experimental use and clinical investi-
gation. Barlow^ has shown this drug to exert
a pronounced action against experimental staphy-
lococcic, streptococcic and pneumococcic infec-
tions, both in vitro and in vivo. Long® has car-
ried out studies on the absorption, distribution
and excretion of the sulfathiazol derivatives in
man. He found that the drug is excreted much
more rapidly than is sulfapyridine. The drug is
excreted both in the urine and the feces. The
drug seems to be distributed in exudates and
transudates in about the same ratio that has been
noted previously for sulfanilamide. HerrelF de-
scribed the clinical use of sulfamethylthiazol in a
case of staphylococcus aureus bacteremia secon-
dary to a staphylococcus infected postoperative
incision with very favorable results. Helmholz*
has showm that the two compounds, sulfamethyl-
thiazol and sulfathiazol, have a definite bacterio-
static effect on strains of staphylococcus aureus
and streptococcus fecalis. He found that in uri-
nary infections, the latter organisms were killed
off by these drugs. Pool and Cook^ have found
the new thiazol drugs to be less toxic than either
sulfanilamide or sulfapyridine. Neither sulfa-

March, 1941

199

bULFAMETHYLTHIAZOL— FINCH, ALPINER AND HUMPHREY

methylthiazol nor sulfathiazol is conjugated by
the body to the extent that sulfanilamide and
sulfapyridine is conjugated. Fitch® described
the use of sulfathiazol in a case of spinal epidural
abscess caused by staphylococcus aureus compli-
cated by septicem'a and pyemia with favorable
results.

We wish to present a case of staphylococcus al-
bus bacteremia complicating a carbuncle of the
nose which was successfully treated by the use
of sulfamethylthiazol.* The drug was admin-
istered after failure to obtain clinical improve-
ment from sulfanilamide and sulfapyridine. The
drug was given in doses of 1 gram every four
hours after an initial dose of 4 grams. On only
one occasion did the patient vomit a short time
after being given the drug, but it was tolerated
well on all other occasions.

Case Report

G. B., a well developed girl of sixteen years, was
admitted to Leila Y. Post Montgomery Hospital, Battle
Creek, Michigan, on February 23, 1939. Her only
complaint was that of a pimple on the right side of
nose in the right nostril for the past four days. This
was gradually getting larger, tender and painful.

Physical examination disclosed a small carbuncle in
the right nostril, the size of a small pea. This area
was reddened and tender. No fluctuation was present.
The anterior cervical glands on the right side of the
neck were slightly palpable. The rest of the physical
examination was negative, and no fever was present
on admittance. The white blood count was 16,500
with 64 per cent polymorphonuclears. Urinalysis
was essentially negative. The patient was put on
sulfanilamide, 15 grains every six hours, along with wet
boric compresses to the nose. Despite this treatment,
the patient’s temperature gradually increased to 103.6°
F. in four days. The carbuncle of the nose had bur-
rowed posteriorly into the vestibule of the mouth. On
February 27, 1940, fluctuation appeared in the mouth
above the upper lip where a small incision was made,
and several drops of pus exuded. The patient was put
on a peroxide mouth wash. The following day, the
patient had a moderately severe chill lasting about
fifteen minutes, followed by a temperature of 105.2° F.
From February 29 to March 3 the patient ran a septic
course with the temperature ranging from 100° F. to
106° F. Her general condition was becoming poorer
associated with apathy, mental sluggishness, no appe-
tite and generalized weakness.

A blood culture was taken following the chill and
a Gram positive Staphylococcus was found. Repeated
blood cultures demonstrated the organism to be Staphy-
lococcus albus. During this entire time the patient
was under sulfanilamide treatment without any im-

*Furnished through the Medical Research Department of
the Winthrop Chemical Company for investigational purposes.

provement. On March 2, 1940, she was put on

sulfapyridine without any remarkable change in her
condition. The following day she was transfused with
250 c.c. of citrated blood. This was followed by a
febrile reaction reaching 107° F. On March 3, 1940,
sulfamethylthiazol was administered with an initial
dose of 4 grams followed by 1 gram every four hours.

Within twenty-four hours the temperature dropped
to 100° F. and within thirty-six hours after treat-
ment was started with the new drug, the tempera-
ture became normal and remained that way until
her discharge on March 20, 1940. The patient made
a remarkable recovery. The carbuncle of the nose
was completely gone two days after initiation of
sulfamethylthiazol treatment.

Four repeated cultures taken after the onset of thiazol
treatment continued to be positive for Staphylococcus
albus. On March 14, 1940, eleven days after beginning
of sulfamethylthiazol treatment, the first sterile blood
culture was reported. This has been repeated on four
different occasions and the blood stream reported sterile.
The patient’s general condition has remained excellent
since her discharge.

Repeated urinalyses have shown no renal damage.
Twenty-three blood counts were taken through the
illness. The red blood cells never dropped below
3,130,000 and the lowest hemoglobin was 57 per cent
at the same time this count was reported. Two trans-
fusions by the indirect citrate method were given.
The white blood count did not show any leukopenia
but there was a tendency to a granulocj’topenia, the
average granulocyte count being about 50 per cent,
while the lowest level was 30 per cent.

Summary

A sixteen-year-old child had a bacteremia
caused by a carbuncle of the right nostril which
burrowed into the vestibule of the mouth. The
elevated temperature and a blood culture positive
for Staphylococcus albus indicated a bacteremia.
Sulfamethylthiazol in moderate amounts were
given with very little toxicity. After eleven
days of therapy, the blood stream became sterile
and has remained so. The patient made a re-
markable recovery.

Bibliography

1. Barlow, O. W., and Womburger : Proc. Soc. Exper. Biol,
and Med., 42:762; (Dec.) 1939.

2. Cook, E. N. and Pool, T. L. : Sulfathiazol and sulfame-

thylthiazol in the treatment of infections of the urinary
tract. Prod. Staff Meetings Mayo Clinic, (Feb. 21) 1940.

3. Fitch, T. : Sulfathiazol in staphylococcus aureus. Arch.

Ped., 57:119-124, (Feb.) 1940.

4. Helmholz, H. F. : The bactericidal effect of sulfathiazole

and sulfamethylthiazole on bacteria found in urinary in-
fections. Proc. Staff Meetings Mayo Clinic, (Jan. 31) 1940.

5. Herrell, W. E., and Brown, A. E. : The clinical use of

sulfamethylthiazole in infections caused by staphylococcus
aureus. Proc. Staff Meetings Mayo Clinic, (Xov. 29) 1939.

6. Long, Perrin H. : Thiazole derivatives of sulfanilamide.

Jour. A.M.A., 114:870-871, (March 9) 1940.

200

Tour. M.S.M.S.

BLOOD BANK— BRINES AND MANNING

Experience with the Blood Bank"^

By Osborne A. Brines, M.D., F.A.C.P.
and

J. Edward Manning, M.D.

Detroit, Michigan

Osborne A. Brines, M.D.

M.D., Detroit College of Medicine and Sur-
gery, 1927. Associate Professor of Pathology,

Wayne University. Pathologist to Receiving
Hospital and Alexander Blain Hospital, De-
troit. Diplomate of American Board of Path-
ology.

John Edward Manning, M.D.

M.D., Western Reserve University School of
Medicine, 1937. Assistant Resident in Surgery,

Receiving Hospital, Detroit.

■ Many medical ideas, fashions and procedures
appear to enjoy recurring cycles of new pop-
ularity, and so it is not surprising that we are
again using a method of blood transfusion which
we practically discarded about twenty years ago.
In 1923 one of us (OAB),^ in discussing direct
transfusions, referred to a method of transfus-
ing citrated blood which we considered satisfac-
tor}", but recommended the direct transfusion
technic as preferable. Recently that same ap-
paratus and technic, slightly modified, has large-
ly replaced direct transfusion methods. The
transfusing of unmodified blood, while unques-
tionably of greater benefit to the patient, never
ceased to be a rather highly specialized technic.
Generally speaking a blood transfusion is a hos-
pital procedure and the comparative simplicity
of the indirect transfusion has led to its wide-
spread adoption in institutional practice. While
this has been somewhat regretful, it has lead to
important developments and advances.

The imagination of both laymen and physicians
was stimulated a few yeas ago by popular ac-
counts from Russia of the transfusing of cadaver
blood. It is difficult to find clear-cut descrip-
tions in the medical literature of results obtained
by Russian investigators,® but at least the idea
of blood storage was firmly implanted. Our
first serious consideration was given the matter
about four years ago after discussing the possi-
bility of blood refrigeration with Fantus,^ who
at that time was contemplating such a step for
Cook County Hospital. There was apparently
very little blood banking done in this country
prior to 1937 but in the past three years most

*From the Department of Pathology, Receiving Hospital, and
Wayne University, Detroit, Michigan.

of the large hospitals in this country have in-
stituted such a service.

Overcoming Objections

The blood bank at Detroit Receiving Hospital
had its beginning in a small way during the
summer of 1937 when an occasional bottle of
citrated blood would be placed in the ice box
of the main laboratory for several days until
the patient for whom it had been taken was in
need of a transfusion. During this period of
development there were many objections from
the various services to using a common blood
bank, the main basis for objection being the
fear that blood put into the bank would be
used for another service and not replaced. Dur-
ing this period it was common practice for
some of the services to hide blood in ward re-
frigerators, thereby establishing a private blood
bank for individual services. During the first
year the bank did not flourish both because the
house staff did not readily adapt itself to the
idea of administering stored blood and because
there was even active opposition ' to the prac-
tice. However, the value of having blood al-
ways available became more and more appreci-
ated, and at the beginning of the second year
the attitude toward the bank changed abruptly
and for the past two years the bank has been
accepted as an indispensable adjunct to institu-
tional medical and surgical practice.

During this period 42,000 patients have been
admitted to the hospital and over 4,000 trans-
fusions administered, all of which have been
given with bank blood.

Considerable financial saving has of course
been possible, but the chief value of the bank
has been the ready availability of blood when
needed and the elimination of the usual con-
fusion attending the selection of suitable do-
nors for transfusions in emergency situations
which frequently arise during the night or on
week-ends, holidays, et cetera.

It is readily admitted that the financial as-
pect of blood bank operation, particularly that
involving the laboratory examination of donors,
is much simpler in a charity hospital than it
might be in a private institution. For this rea-
son and because of the large number of trau-
matic cases cared for, the bank is a particular
necessity in a hospital of this type.

M.\rch, 1941

201

BLOOD BANK— BRINES AND MANNING

Source of Blood

An important consideration, of course, in the
operation of a blood bank is the source of blood.
It is customary for a member of the resident
staff to approach the relatives or friends of any
patient presenting indications for a transfusion.
The need is explained to the family without
frightening them, the point being made that a
transfusion is no longer a life and death pro-
cedure but is a commonly employed form of
therapy. Frequently such a plea results in more
blood being contributed for that patient than is
necessary, the excess profit being used for other
patients who have no friends or relatives. We
never have encountered any difficulty with
donors who felt that they had contributed too
much blood.

Administrarion of the Bank

Eight clinical services* participate in the bank
which is controlled by a committee composed of
a resident from each major service, including
pathology inasmuch as the department of pathol-
ogy is chiefly responsible for the operation and
administration of the bank. This committee
meets once a week at which time problems per-
taining to the bank are discussed. It has not
been found necessary to establish a transfusion
team ; the internes, under supervision and with
modern equipment, are able to take and give
blood without difficulty.

Good bookkeeping is necessary in order that
all blood is fully accounted for at all times and
that proper data are available for statistical pur-
poses. A separate balance sheet is kept for each
service and a report is rendered every forty-eight
hours showing the credit or debit of each serv-
ice. When the interne deposits blood in the
bank the technician in charge gives that blood
an identifying number and credits his service
with the amount of blood deposited ; the reverse
is done when blood is withdrawn. The intern
depositing the blood fills out a “donor card”
upon which is written pertinent data concerning
the donor including the date, donor’s name and
address, history of venereal disease, serum sen-
sitivity, allergy or malaria, and the number of
hours since the last meal, together with a state-
ment that he or she is physically fit to serve as
donor from a clinical viewpoint. Later the blood
group and result of the blood test for syphilis
are entered on this card.

When blood is withdrawn from the bank
cross matching with the recipient is performecl
and a “recipient card” of a different color if
attached in place of the “donor card.” Th<
technician writes the bank blood number on thif
card and later the intern records such dat?
as date, name of recipient, case number, ward
service, amount of blood given, the indicatior,
for and time required to give the transfusion
Various signs and symptoms of a reaction are
listed on this card such as chill, dyspnea, cya-
nosis, pain, urticaria, et cetera. These are
checked when noted and space is available foi
describing any reaction which might occur. On
this card is also space for recording temperature
readings taken before the transfusion and every
half hour after the start of the transfusion, re-
gardless of the time required for the blood tc
run in. Later these cards are stapled back tc
back and a complete record of the transfusion
is thus provided. The pairing of these card^
insures against failure to fill out the recipient
card.

Technic of Use fi

The transfusion apparatus used in this hos-
pital is essentially that described by Cooksey.'
The flask has a capacity of 700 c.c. and is
equipped with a rubber bulb for creating a par-
tial vacuum. 100 c.c. of a 2 per cent solution of
sodium citrate are placed in the flask for 500
c.c. of blood. The transfusion sets, as well
as all intravenous apparatus, are cleaned and
sterilized in a central supply room by two
nurses who are experienced in this work. The set
is completely assembled before sterilization, thus
reducing the chance of contamination on the
ward. The citrate solution is not placed in the
flask before sterilization chiefly because it is felt
that aspirating the citrate solution into the flask
before the transfusion has the advantage of
moistening all surfaces with the anticoagulant.

Certain minor technical steps and procedures
are important. Gentle handling of the blood at
all times is insisted upon because agitation has-
tens hemolysis and increases the incidence of
post-transfusion reactions. A sample of un-
citrated donor’s blood is placed in a small test
tube which is taped to the large flask and from
this necessary laboratory tests can be made.
These tests are not performed until the blood
is deposited in the bank. Positive blood tests j.

Tour. M.S.M.S.^

202

BLOOD BANK— BRINES AND MANNING

for syphilis among our donors have not ex-
ceeded 2 per cent and we feel that the discard-
ing of this negligible amount of blood is less
objectionable than the confusion and annoyance
entailed in checking the donors previously. The
temperature of the refrigerator should be kept
between 0° and 5° C. at all times, preferably
around 2°. Our refrigerator has an automatic
recording thermometer which is a distinct advan-
tage.

Technical Experiences

Our experiences with the bank have been in-
teresting and instructive and our ideas regard-
ing the relative importance of various factors
have changed several times.

At the beginning we believed that the blood
could be stored for at least three weeks. Now
we believe that a maximum of a week is pref-
erable.

1

It has been stated that the life span of fresh
erythrocytes in the circulation of the recipient
is about 120 days and that span decreases six
days with each day of storage. Furthermore,
it has been found that the prothrombin content
: of the plasma decreases to a level of 60 per
, cent at the end of the third week.® Therefore,
if blood is given either to correct anemia or
for its hemostatic effect it should be compara-
tively fresh. Donor’s cell suspensions are kept
taped to the flask of blood while it is in the
bank, and before using a direct matching is per-
formed between recipient’s serum and donor’s
cells.

As previously stated by one of us (OAB),^’^
type O (Moss IV) donors can be used univer-
sally with safety. This statement, while ob-
viously true, has been challenged by several
writers and even today the opinion is stubbornly
adhered to by some that donors of the recipient’s
group are preferable.

Experience has proved that the use of uni-
versal donors is a safe practice.

'■ The reason is clear : the cells of group O
^ blood possess no agglutinogens and, therefore,
cannot be agglutinated. This is an important
point and has contributed considerably to the
^ safety of blood transfusions.

^ M.^rch, 1941

In the experience of Diggs and Keith,®
hemolysis of bank blood is an important factor
in the production of transfusion reactions. Fol-
lowing this suggestion we performed a hemolysis
test, consisting simply of centrifuging a small
amount of thoroughly mixed blood taken from
the transfusion flask. In several hundred con-
secutive transfusions we found that after the
tenth day hemolysis increased rapidly, but was
negligible within the first week, seldom more
than one or two plus and usually none. A
study of 400 transfusions convinced us that
hemolysis up to and including two plus was
not a factor in producing post-transfusion reac-
tions and we concluded that in giving bank
blood which had been properly handled and
stored at the proper temperature for less than
ten days the hemolysis factor could be disre-
garded.

Other laboratory tests to be performed on
banked blood should be considered. The per-
centage of hemaglobin should doubtless be de-
termined but a routine leukocyte count is hardly
necessary\ Blood cultures have been run on
over 100 bank bloods at the time of administra-
tion but the blood was given without waiting
for the result. In several instances the cultures
were positive for non-pathogenic micro-organ-
isms but no reactions or other ill effects were
produced.

Considering the fact that any bacteria pres-
ent will be in small numbers and probably non-
pathogenic, and the natural bactericidal prop-
erties of the recipient’s blood, it would seem
that the taking of blood cultures routinely
from bank blood when it is used is both
unnecessary and impractical.

Furthermore, removing samples of blood
from the storage flask for various laboratory
tests invites contamination and should be
avoided.

Brem, Zeiler and Hammack^ and others
have stated that the use of fasting donors re-
duces the incidence of post-transfusion reactions.
In 1,500 transfusions given during the past eight
months at this hospital the results have been
carefully studied and recorded. Attention has
been given to the interval between the time
of the last meal and the giving of blood and
we have found that there has been not the

203

PLASMA BANK— BRINES AND MANNING

slightest relationship between the two. We have
obtained the same information regarding the
ingestion of alcohol and the same can be said
of alcohol as of food.

%

The speed of giving the blood has also been
studied and we have been forced to the con-
clusion that the optimum time for a trans-
fusion, as far as reactions are concerned, is
from sixty to ninety minutes. Several months
ago we discontinued heating the blood before
giving it and our figures would indicate that
this change has reduced the percentage of re-
actions. The chief objections to heating ap-
pear to be frequent overheating and undesir-
able agitation while heating. Over 1,000 con-
secutive transfusions of cold blood have been
given, frequently out of the refrigerator less
than thirty minutes. The only untoward result
of this practice, that we have been able to see,
has been a local cooling of the tissues in and
around the antecubital fossa and this did not
seem to annoy the patient.

To discuss the percentage of post-transfusion
reactions is difficult be«ause in no two series of
cases are the same criteria used. Because such
a discussion has little comparative value if will
be omitted here. The amazingly low percentage
of reactions in some series would indicate that
very liberal criteria are sometimes employed.

It is doubtful if, in the light of present day
knowledge and experience, any large or moderate
sized hospital would care to function without
a blood bank. In our experience it has been
a valuable asset in reducing transfusion delay,
in eliminating the confusion and extra labor
caused by the testing of donors for emergency
transfusions, and in a large saving of money
formerly spent for professional donors. In the
past two years no professional donors have been
employed at Receiving Hospital.

One of the most important developments of
the blood bank has been in the plasma bank.
This will be discussed by us in a subsequent is-
sue of The Journal.

Bibliography

1. Brem, W. V., Zeiler, A. H., and Hammack, R. W. : Use

of fasting donors. Am. Jour. Med. Sci., 175:96, 1928.

■2. Brines, Osborne A.: The transfusing of unmodified blood.

Arch. Surg., 7:306, 1923. - c j i

3 Brines Osborne A.: The transfusing of unmodified blood

(IV): Arch. Surg., 16:1080, 1928.

204

4. Brines, Osborne A.: Fatal post-transfusion reactions. Jour, i

A.M.A., 94:1114, (Apr. 12) 1930.

5. Cooksey, W. B.: New apparatus for storing, filtering and 1

administering blood. Am. Jour. Surg., 49:526, 1940.

6. Diggs, L. W., and Keith, A. J. : Problems in blood bank-

ing. Am. Jour. Clin. Path., 9:591, 1939.

7. Fantus, B. : Therapy of Cook County Hospital; blood pres-

ervation. Jour. A.M.A., 109:128, (July 10) 1937.

8. Lord, J. W., and Postore, J. B.: Plasma prothrombin con-

tent of bank blood. Jour. A.M.A., 113:2231, (Dec. 16)
1939.

9. Yudin, S. S.: Transfusion of stored cadaver blood. L-ancet,
2:361, (Aug. 14) 1937.

Development of the Plasma
Bank*

By Osborne A. Brines, M.D., F.A.C.P.
and

J. Edward Manning, M.D.
Detroit, Michigan

Osborne A. Bbines, M.D.

M.D., Detroit College of Medicine and Sur-
gery, 1927. Associate Professor of Pathology,
Wayne University. Pathologist to Receiving
Hospital and Alexander Blain Hospital, De-
troit. Diplomate of American Board of Path-
ology.

John Edward Manning, ^I.D.

M.D., Western Reserve University School of
Medicine, 1937. Assistant Resident in Sur-
gery, Receiving Hospital, Detroit.

■ As WAS stated in a previous article,^ a most
fortunate outcome of the blood bank has been
the plasma bank. During the past year great
interest has developed in the giving of plasma.
Considerable impetus was given the subject by
the extensive work done on shock by Moon,^
and Blalock.^’^’^’^ These investigators found
that the most serious change undergone in shock
was diminution of circulating fluid volume, the
capillary walls becoming more permeable, lead-
ing to the escape of plasma into the tissues. A
vicious cycle is set up with more and more cir-
culating fluid being lost resulting in hemocon-
centration. It has been found that the admin-
istration of glucose and salt solution has but a
fleeting effect upon blood volume, inasmuch as
these substances exert no appreciable osmotic
pressure within the vessels which might operate
to draw lost fluid back into the circulation, but
instead are rapidly diffused out through dam-
aged capillary walls into the tissues (Fig. 1). It
was obvious that the most satisfactory treatment
for shock was the introduction into the blood
stream of some substance which would raise

A"rom the Department of Pathology. Receiving Hospital, and
Wayne University, Detroit, Michigan.

Jour. M.S.M.S.

PLASMA BANK— BRINES AND MANNING

I osmotic pressure and would not rapidly diffuse
I out from the circulation. Whole blood partially
i fulfilled the requirements. However, when
j hemoconcentration exists there is little advan-
I tage to introducing more blood cells which, when
{ not needed, are more or less inert. In other
' words, under such conditions, a whole blood
j transfusion really amounts to giving equal
I amounts of useful and inert material.

1;

! Blalock has stressed the use of plasma as
the ideal treatment for shock from all causes
and it has been known for years that plasma
is a valuable therapeutic agent in cases of
severe bums. It now seems apparent that
plasma is preferable to whole blood in all
emergencies where transfusions have been em-
ployed in the past except carbon monoxide
poisoning, where normal red cells are badly
needed. Severe hemorrhage is no exception
to this statement because here it is shock
and not anemia which endangers the patient’s
life and which must be combated promptly
and forcefully. We are coming to realize that
the chief indications for whole blood transfu-
sion are to correct severe acute anemia from
hemorrhage after the patient has been restored
from shock and to correct severe chronic anemia
where drug therapy is either inadequate or
impractical, e.g., in preparation of an anemic
patient for operation.

Prior to the advent of the blood bank, plasma
was not readily available but today it is a nat-
ural by-product of the former. Gravitation
alone is necessary to separate cells from plasma.
Centrifugation yields slightly more plasma but
is not necessary. In the beginning it was our ,
practice to separate the plasma from cells only
after it had been in the bank for some time
(about fourteen days) and apparently was not
going to be used. Now we attempt to antici-
pate the amount of whole blood necessary, being
sure to keep an adequate supply of Group O
(Moss IV) available, and then to convert the
remainder into plasma while it is only a few
days old. Berkefeld filtration will produce plas-
ma of superior appearance, and of course would
insure sterility, but we do not feel that this
is necessary. The fine shreds and flocculi fre-
quently found in plasma, which apparently orig-
inate from foam, are not objectionable and more

or less disappear upon agitation. As in the ad-
ministration of refrigerated blood, it does not
appear necessary to heat plasma before using.

At Detroit Receiving Hospital plasma trans-
fusion had its origin in the realization that too

CASE 41 MINUTES

and plasma in a case of perforated gastric ulcer.

much blood was being discarded because it was
not being used within the limit of fourteen days,
which we observed at that time. It was felt
that a too valuable therapeutic commodity was
being discarded. The surgical staff administered
some of this plasma to a few shock and burn
cases and were favorably impressed by the re-
sults obtained. The success of 40 or 50 such
transfusions made it apparent that more than the
accidental accumulation of plasma would be
necessary to supply the needs of the hospital.
A more systematic production of plasma was,
therefore, instituted. It was at this time that we
became convinced that our supply of plasma
should be obtained from fresh bank blood.
After separation, the plasma can be kept in the
refrigerator for weeks or months. If desired
to store for an unusually long time it could be
concentrated by lyophilizing.®

Preparing the Plasma

The method of preparing plasma in this hos-
pital has been reduced to its simplest form.
At the end of twenty-four hours the citrated
blood has usually separated into two distinct
layers with the supernatant plasma assuming a
clear yellow color. At the end of three days
maximum packing of the cells has occurred.

March, 1941

205

PLASMA BANK— BRINES AND MANNING

TABLE I. AGGLUTININ TITER OF 412 SPECIMENS

OF SERUM OR PLASMA

Highest

Number of

Dilution

Specimens

1-2

3

1-4

18

1-8

34

1-16

60

1-32

100

1-64

82

1-128

68

1-256

32

1-512

14

Over 512

1

Total

412

Our method of removing the plasma has been
to use a regular blood-taking set and by sub-
stituting a capillary or opsonic pipette for the
needle adaptor the plasma can be aspirated into
a regular transfusion flask, practically a closed
system being maintained. Between 25 c.c. and
50 c.c. (about 1 cm.) of plasma will be lost be-
cause of cell contamination. If desirous of re-
covering this small amount, this thin layer of
plasma could be transferred to one or two 50
c.c. centrifuge tubes and the cells thrown down.
We have felt that the loss of this small amount
of plasma was negligible compared with the
labor necessary to recover it, together with the
possibility of bacterial contamination, and have
adhered to careful aspiration to the point where
cells begin to be removed. Each flask will con-
tain about 450 c.c. of plasma representing one
liter of whole blood.

When the plasma is placed in the refrigera-
tor a “plasma card” of characteristic color is
attached, upon which the same information is
recorded as upon the “recipient card” in the case
of whole blood, except that in addition blood
pressure readings taken before and after the
transfusion are recorded. The same bookkeep-
ing method is used as was described in blood
banking except that when 450-500‘ c.c. of plasmas
is dispensed, the service using it is charged
with a liter of blood, making one set of books
serve for both commodities.

Technical Advantages of Plasma

The technical advantages of giving plasma
are obvious. Firstly, it is a no more compli-
cated procedure than giving glucose intravenous-
ly. Secondly, plasma can be administered with-
out determining either the blood group of the
plasma or of the recipient. Plasma which is

capable of agglutinating the recipient’s cells in
vitro does not do so when administered intra-
venously because its agglutinins are thereby so
diluted that its agglutinin titer falls to an im-
potent level. Table I illustrates the agglutinin
titer which we found in 412 specimens of serum
and plasma. Even plasma possessing a high
agglutinin titer has not been found to produce
an incompatibility reaction. In about one-half
of our plasma transfusions, theoretically incom-
patible plasma has been given without the pro-
duction of a single reaction. While we have
determined the agglutinin titer of all plasma
given, we consider it of no practical importance.
It is preferable to pool two or more lots of
plasma thereby reducing its agglutinin titer.
This is particularly true if unlike types of plasma
are pooled. In giving plasma, posttransfusion
reactions are negligible and it can be said with-
out reservation that the blood group can be
disregarded. The time usually consumed by
these laboratory procedures is thus saved, mak-
ing plasma transfusions more adaptable to emer-
gency situations.

The use of plasma without regard for its
blood group is based upon the same funda-
mental logic as the successful use of universal
whole blood donors. The cells of group O
blood contain no agglutinogens and plasma
contains no blood cells. The two situations
are identical from the standpoint of incom-
patibility, agglutination not being possible in
either instance. Being able to disregard blood
groups in giving either whole blood or plasma
is a decided advantage considering the grow-
ing complexity of isohemagglutination and the
recognition today of at least six types of
blood.® The successful use of plasma without
regard for its blood group should eradicate all
remaining opposition to the employment of
universal whole blood donors.

An additional advantage of plasma over whole
blood is the speed with which it can be given.
We have no evidence that plasma can be given
too rapidly. The majority of the plasma trans-
fusions at this hospital have been given at the
rate of 500 c.c. in less than twenty minutes,
many in ten minutes and a few in five to seven
minutes. Plasma, because of its lower specific
gravity and viscosity runs through the needle

206

Jour. M.S.M.S.

PLASMA BANK— BRINES AND MANNING

much more rapidly than does whole blood. In
one instance 500 c.c. of plasma was given in
twelve minutes, whereas, with the same needle,
apparatus and giving conditions, the subsequent
giving of 500 c.c. of whole blood required 88

CASE 47 MINUTES

P'ig. 2. Chart showing relative speed and therapeutic value
of plasma and whole blood transfusion in a case of severe shock.

minutes (Fig. 2). Had this patient been forced
to wait for an hour and a half to receive her
first 500 c.c. of sustaining fluid, it is felt that
the outcome might have been fatal.

Summary

The plasma bank at Receiving Hospital has
been the direct and natural out-growth of the
blood bank and is rapidly assuming an impor-
tant role in transfusion therapy. Nevertheless,
there are sufficient indications for giving both
whole blood and plasma to warrant the continu-
ance of the two as integral parts of the blood
bank set-up. Considerable reluctance, on the
part of the clinical staff, to give plasma had to
be overcome in the beginning. This same atti-
tude was exhibited in the early days of the
blood bank. However, once either bank is prop-
erly used and fully appreciated, any attempt at
abolishment would probably meet with firm op-
position.

The outstanding advantages of plasma trans-
fusion are the speed and safety with which the
plasma can be given and its greater efficacy in
the treatment of such conditions as shock, burns,
diabetic coma, et cetera. Here the double dosage

of plasma is a great physiological and chemical
asset, while blood cells are unnecessary.

One’s thoughts naturally turn to the possibil-
ity and feasibility of further development of the
plasma bank in the direction of seeking other
sources of plasma or serum. Possibly the tox-
icity of animal serum for human administra-
tion has been overestimated or the serum could
some way be rendered non-toxic. It has been
stated by some that human blood serum is more
toxic than plasma, some toxic substance or sub-
stances being formed or liberated during clot-
ting. This has been disputed by others. Ca-
daver blood as a source of plasma and serum
has to be considered. It has been shown that
blood from the jugular vein of non-infectiouS
individuals taken within a few hours after death
is bacteria-free. As an extra precaution, Berke-
feld filtration could be employed. These sources
of plasma and serum probably would not have
to be resorted to in civil practice, but the necessi-
ties of military practice should not be overlooked
at this time.

Bibliography

1. Blalock, A.: Mechanism and treatment of experimental

shock. Arch. Surg., 15 ;762, 1927.

2. Blalock, A.: Experimental shock. Arch. Surg., 20:959,

1930.

3. Blalock, A. : Shock of peripheral circulatory failure. South.
Surgeon, 7:150, 1938.

4. Blalock, A., and Bradburn, H. : Distribution of blood in
shock. Arch. Surg., 20:26, 1930.

5. Brines, O. A., and Manning, J. E. : Experience with the

blood bank. Jour. Mich Med. Soc., 40:201, 1941.

6. Flosdorf, E. W., and Mudd, S. : Procedure and apparatus

for preservation in lyophile form of serum and other bio-
logical substances. Jour. Immunol., 29:389, 1935.

7. Moon, V. H. : Shock, its mechanism 'and pathology. Arch.

Path., 24:642, 1937.

8. Wiener, A. S. : Blood groups and blood transfusion. Bal-
timore: Chas. G. Thomas, 1935. P. 12.

SELECTIVE SERVICE REJECTIONS

Rejection of one-third of the men applying for army
service in the New York area is remediable by medical
care only to a small extent, according to the January
issue of the NeTV York State Journal of Medicine,
official organ of more than 17,000 physicians of the
state.

“The defects for which men are being rejected by
the army examiners,” The says, “are those struc-

tural and psychologic weaknesses upon which the stren-
uous nature of field training could be expected to have
a detrimental effect.

“The point of view of the army and of civilian medi-
cal examiners might be expected to vary considerably
concerning the acceptability of certain risks and thus
to account for the high percentage of rejections. They
should not be taken too seriously even by constitutional
pessimists. And, after all, what can be done for flat
feet, bow legs, and perforated eardrums ?”

Unfitness for medical service is not necessarily an
index of health, according to The Journal, though
“some of our socialist acquaintances start right away
to yell louder for state medicine.” — Medical Society
OF THE State of New York.

March, 1941

207

RHEUMATIC FEVER— RIECKER

Rheumatic Fever

Preventive Aspects*

By Herman H. Riecker, M.D.
Ann Arbor, Michigan

may be distinguished by the following: they {
occur at the end of the day and during the night ^
in the muscles of the legs and thighs about the *
joints rather than in them. There is no heat,
swelling or pain on motion.

Incidence

Herman H. Riecker, M.D.

M.D., Johns Hopkins Medical School, '

1923. Associate Professor of Internal
Medicine, University of Michigan Med-
ical School. Member of the Michigan
State Medical Society.

■ Rheumatic fever is a specific contagious
familial disease of childhood characterized usu-
ally by joint pains, mitral stenosis, chorea and
fibroid nodules. However, the disease may occur
insidiously without joint symptoms, chorea, or
nodules, and since febrile illnesses with phar-
yngitis are not uncommon in children the prob-
ability of cardiac crippling may remain quite un-
recognized.

Chorea in children may occur independently
of rheumatic activity, one-half the cases studied
by Coburn and Moore^ in New York occurring
in non-rheumatic subjects. Gerstley and associ-
ates'^ in Chicago, and Jones and Bland^ in Boston
found that many children with chorea did not
have other rheumatic manifestations. Since al-
most one-half of the cases occurred in non-
rheumatic subjects, each case of chorea must
be differentiated with respect to possible rheu-
matic fever. The differential diagnosis will be
mainly between encephalitis, hysteria, Hunting-
ton’s chorea, chorea des degenere, nervous tics,
congenital syphilis, and chorea gravidarum.

Between the ages of five and nine years, the
onset of the rheumatic fever may be sudden,
with severe pancarditis, or insidious, with
fatigue, vague joint pains and mild fever. A
constant apical systolic murmur may be the
only evidence of damage to the heart since the
presystolic murmur of mitral stenosis usually
is absent before the tenth year. The child who
tires easily, is losing weight, with a poor appe-
tite, pallor and indefinite muscle pains should
arouse the suspicion of the physician that he
is dealing with the insidious form of rheumatic
fever. Polyarthritis is not as frequent in child-
hood as in later life, and may be entirely absent.
Non-rheumatic “growing pains” of childhood

*This article is submitted for publication at the request of
the Subcommittee on Heart and Degenerative Diseases of the
Michigan State ISIedical Society.

Predominantly a disease of childhood and
early adult life, with slightly greater incidence
in girls, it ranks first as a cause of death in
girls in New York City and is second to ac-
cidents among boys.

Its incidence in Michigan is unknown. The
disease has been made reportable in the State
for the purpose of determining the incidence
and to permit more specific preventive meas-
ures.

In Northern United States the incidence
of rheumatic fever is estimated at between 1
and 5 per cent. Woofter’s^® careful studies in
West Virginia indicate a higher percentage (4.4
per cent) than is usually found. Martin^^ esti-
mates the national incidence at 800,000 to one
million cases per year and an annual mortality
of about 40,000. Martin followed 1,378 children
for 18 years and found a mortality rate of 28.7
per cent. More than half these died within the
first five years of their initial infection. Death
occurs more commonly during the second or
third attack, usually between five and twelve
years of age.

According to Meakins^^ the disease is seven
times more common in urban than in rural school
populations. He writes that mitral stenosis is
twenty times more frequent in Boston than in
New Orleans, and fourteen times more frequent
than in Dallas. J. T. Clarke^ found no cases of
mitral stenosis in thirty-three years in the tropics.
In 571,526 out-patients from an estimated popu-
lation of 33,748,569 he saw 747 cases of joint
and other manifestations, with fever, obviously
rheumatism, but no observable rheumatic heart
disease.

En\dronment

Sir Leonard HilP discouhts to some extent
the effect of climate alone and writes that “the
evidence shows that it is conditions produced
by dirty, artificially-heated and ill-ventilated
houses, and density of {xipulation which cause

208

Jour. M.S.M.S.

RHEUMATIC FEVER— RIECKER

rheumatic troubles, the ill-effect of these condi-
tions being intensified by a diet in which pro-
tective foods are deficient.” In England damp-
ness of houses is considered the most important
local environmental predisposing factor.

May Wilson^® believes also that adverse local
or home environmental conditions are extremely
important because in New York the disease is
so much more common among the lower than
the higher economic classes. Swift, Wilson and
Todd^^ find the disease about twenty times more
common among the working classes than among
the rich and agree that overcrowding, bad sani-
tation, dietetic insufficiency, and dampness are
important predisposing factors. There is a
marked seasonal variation, the disease being
much more common in early spring when upper
respirator}" infections are prevalent.

Familial Incidence

The familial incidence of rheumatic fever is
interesting in that both a tissue susceptibilit}'
and a contagious factor may explain the occur-
rence of the disease in other members of the
family in 50-75 per cent of the cases. Kaufmann
and Scheerer’s^® contribution on the appearance
of the disease in 72 pairs of twins supports the
constitutional susceptibility factor, while such
cases as. Swift’s support the purely infectious
factor. In Swift’s case of a child with repeated
attacks, removal of badly diseased tonsils from
the mother resulted in complete cessation of re-
crudescences of rheumatic fever in the child.

Gauld® and associates found in two genera-
tions a rheumatic family history 3.7 times as
high in 96 rheumatic, children as in the control
families.

Etiology

Rheumatic fever most clearly is an infection.
It has been seen in epidemics, and its clinical
features are those of infection. The hemolytic
streptococcus is closely concerned as a precipitat-
ing agent but it has not been proved the cause
of the infection.

The entrance of the infectious agent through
the upper respiratory tract seems established.
'‘One must appreciate,” as Meakins^^ remarked,
“that the whole mucous membrane of the fauces
and pharynx is the probable portal of entry.”
Coburn and Moore^ conclude that the “evolution
of rheumatic fever consists of three phases:

March, 1941

first, a phase in which there is fever and an in-
fection of the respiratory tract with the hemo-
lytic streptococcus subsiding in a few days ; sec-
ond, an afebrile, symptom-free phase in which
the immune response develops in the rheumatic
subject with a diminution of serum complement
and, finally, the acute attack which is phase
three.” A month may elapse before the phase
three appears.

Tonsillectomy

It has been shown by numerous studies that
tonsillectomy does not usually affect favorably
the course of rheumatic disease, and may pre-
cipitate either a recrudescence, or rarely sub-
acute bacterial endocarditis in a susceptible indi-
vidual. Recrudescences occur in a high per-
centage of cases whether or not a tonsillectomy
has been done.

In Baltimore, Allan and Baylor^ found that
in 108 patients subjected to tonsillectomy and
adenoidectomy between 1910 and 1924, recrude-
scence had occurred in 43.5 per cent. Rachel
Ash^^ concluded from a study of 522 children
in Philadelphia that tonsillectomy did not pre-
vent recurrences of rheumatic manifestation, nor
did the presence or absence of tonsils have any
demonstrable influence on the possible cardiac
involvement. The infective agent seems to enter
the body through the lymphoid tissue of the
whole nasophar}-nx, of which tonsillar tissue is
but a part.

Tonsillectomy in the rheumatic child is indi-
cated if there is definite disease of the tonsils,
not alone because the child has the rheumatic
tendency. If tonsillectomy definitely will im-
prove the health of a child, it will be of value
for the rheumatic child. No operative proce-
dures should be carried out during the active
phases of rheumatic fever.

As Spaulding^® has emphasized, the greatest
harm has been done by thinking in terms of
“acute” as applied to rheumatic fever. The
preventive principles of tuberculosis would have
been greatly retarded had we begun with the
phrase “acute pulmonary tuberculosis.” Preven-
tive efforts have been long delayed by this ap-
plication of the term to rheumatic fever.

209

RHEUMATIC FEVER— RIECKER

Activity of the Infection

The activity of the rheumatic process may
be evaluated by:

The fever, heart rate, and joint pains.

Number and appearance of the leukocytes.

The sedimentaition rate.

General appearance of the child.

The presence of anemia, weight changes, and
fatigue.

A normal temperature with or without sali-
cylates does not prove inactivity. The diagnosis
of active rheumatic endocarditis may be dif-
ficult unless all the febrile states of childhood
are kept in mind. The over-active heart with
tachycardia, at times a gallop rhythm and soft
sounds, accentuation of the second pulmonic
sound, and a soft systolic murmur should be
noted. Enlargement of the heart shadow by
x-ray is valuable evidence, both in denoting ac-
tivity and in following cases.

The constant tendency for recrudescence
with further cardiac damage makes prognosis
difficult in any case. About 80 per cent of chil-
dren having rheumatic fever develop rheu-
matic heart disease. The severity of the joint
inflammation is no criterion of possible in-
volvement of the heart, since the latter may
occur without joint manifestations. In general,
the later in life rheumatism manifests itself
the less likelihood there is of rheumatic car-
ditis and recrudescences.

The rheumatic process should be considered
active until proved otherwise. Exactly the same
attitude should be maintained regarding activity
as in tuberculosis in order tO' err on the side of
safety. Prolonged rest in bed, well protected
from upper respiratory infection, is as essential
as for pulmonary tuberculosis and may prevent
permanent disability.

The less common manifestations of rheu-
matism should be recognized such as mild chorea,
erythema multiforme (annulare, marginatum,
nodosum), and other toxic manifestations,
anemia, epistaxis, sweating and fatigue. The
first and often the only early symptom is fatigue.

Early recognition of the disease, that is, at
the time of the initial tachycardia and fever, is
important in a disease characterized by a pro-
longed course and frequent cardiac crippling. In

the susceptible person frequent observation for
activity should be made.

Anticipation

Several factors of anticipation of the disease
or its recrudescence in susceptible persons may
be utilized :

(a) Children in Northern urban areas from
the low income families contribute the great
majority of cases.

(b) The local environment, particularly the
factors of overcrowding, dampness, and poor
food are contributing factors.

(c) Children of families in which streptococcic
infection, tonsillitis and scarlet fever are occur-
ring, and those in which even distant relatives
have rheumatic heart disease should be partic-
ularly observed.

(d) Hemolytic streptococcic infections in other
members of the family may initiate an attack in
a susceptible child. The immediate isolation of
upper respiratory tract infections in susceptible
families is therefore advisable.

Preventive Aspects of Rheumatic Fever

The care of the quiescent rheumatic patient
is of special importance and here the principle
of the menace of the herd is used.

(a) The disease should be considered con-
tagious.

(b) Preventive measures may take the same
form as in tuberculosis.

(c) The rheumatic child is “a crippled child
who does not limp.” The advantages of spe-
cial hospitals similar to those now used for
tuberculosis should be recognized.

(d) A person who has once had rheumatic
fever is always susceptible to subsequent attacks.

(e) The encouragement when feasible of
migration of susceptible families to a southern
climate, or at least the avoidance of dampness
and chilling.

(f) The use of small doses of sulfanilamide
or related compounds as a prophylactic during
the winter months has been suggested.

(g) These drugs should not be used during
an acute phase of the disease.

(h) The person with mitral stenosis must
be protected from colds and sore throats in other
members of the family, in schoolmates and at-
tendants. The disease is not only initiated by
upper respiratory infection in one-half of the

210

Jour. M.S.M.S.

RHEUMATIC FEVER— RIECKER

cases, but recrudescence occurs in one-half the
cases following a cold or sore throat. Chilling,
psychic trcmma, and minor operations may pre-
cipitate an attack. These children should be in
bed during the time of any respiratory infection.

(i) Rheumatic children should be guarded
with respect to exercise and their activities con-
stantly directed to sedentary interests. Rest pe-
riods during the day and warm sleeping rooms
should be provided.

(j) The food intake is best managed by insur-
ing adequate vitamins and minerals and the
avoidance of overweight and underweight.

(k) The mental hygiene aspects of a child
afflicted with rheumatic heart disease deserves

I special attention because of the possibility of
I creating additional disability through an inferior-
' ity complex. Frank discussion with the parents
' usually prepares for a satisfactory life adapta-
tion in individual cases.

(l) Allergic children are unusually susceptible
to upper respiratory infection. A careful family
history, examination of the nasal mucosa, and
a determination of eosinophilia in blood and

: nasal secretions is helpful. If the rheumatic
j child exhibits nasal or bronchial allergic changes,
a thorough study directed toward its control
might be of value in limiting the susceptibility
to the rheumatic process.

i (m) In any family, a member of which has
I had rheumatic fever, cultures on a blood agar
' plate of the nasopharynx of all members of the
j family and other contacts should be carried
! out during the winter. Protection against the
! hemolytic streptococcus ‘"carrier” is essential to
the prevention of recurrences in children suscep-
; tible to rheumatic fever.

1 The similarity of rheumatic fever to tuber-
: culosis in its familial incidence, its relation to
; poverty, its tendency to attack the young, its
' constant recurrences with mental or physical
I strain, surgical procedures, or exposure to cold,
, its peculiar immunological reactions, and the
standard procedure in treatment should be of
1 value in a better appreciation of the preventive
t aspects of the disease. Finally, rheumatic fever
should be more frequently suspected by the phy-
sician in dealing with any indeterminate infec-
tion of childhood.

References

1. Allan, W. B., and Baylor, J. W. : Influence of tonsillectomy
upon the course of rheumatic fever and rheumatic heart
disease. Study of 100 cases. Bull. Johns Hopkins Hos-
pital, 63:111-123, (Aug.) 1938.

2. Ash, R. : Influence of tonsillectomy on rheumatic infection.
Am. Jour. Dis. Child., 55:63-78, (Jan.) 1938.

3. Clarke, J. T.: The geographical distribution of rheumatic

fever. Jour. Trop. Med. & Hyg., 23:249-258, (Sept. 1),
1930.

4. Coburn, A. F., and Moore, L. V. : Independence of chorea
and rheumatic activity. Am. Jour. Med. Sci., 193:1-4,
(Jan.) 1937.

5. Coburn, A. F., and Moore, L. V.: Prophylatic use of

sulfanilamide in streptococcal respiratory infections with
especial reference to rheumatic fever. Jour. Clin. Investi-
gation, 18:147-155, (Jan.) 1939.

6. Gauld, R. L., Ciocco, A., and Read, F. E. M.: Further

observations on the >ccurrence of rheumatic manifestations
in families of rheumatic patients. Jour. Clin. Investigation,
18:213-217, (March) 1939.

7. Gerstley, J. R., Wile, S. A., Falstein, E. I., and Gayle, M.:
Chorea: is it a manifestation of rheumatic fever? Jour.
Pediat., 6:42-50, (Jan.) 1935.

8. Hill, L. ; Rheumatism and climate. Brit. Med. Jour.,
2:276-278, (Aug. 5) 1939.

9. Jones, T. D., and Bland, E. F. : Clinical Significance of

chorea as a manifestation of rheumatic fever. Jour.
A.M.A., 105:571-577, (Aug. 24) 1935.

10. Kaufmann, O., and Scheerer, E. : tiber die Erblichkeit des
akuten Gelenkrheumatismus. (Untersuchungen and 72
Zwillingspaaren). Ztschr. f. Menschl. Vererb. u. Konstitu-
tionslehrer, 21:687-696, 1938.

11. Martin. A. T. : Clinical aspects of rheumatic fever in chil-
dren. Bull. N. Y. Acad. Med., 16:475-482, (July 19) 1940.

12. Meakins, J. C. : Rheumatic fever. Canad. Med. Assn.

Jour., 39:426-429, (Nov.) 1938.

13. Spaulding, E. G.: Personal communication

14. Swift, H. F., Wilson, M. G., and Todd, E. W. : Skin re-

actions of patients with rheumatic fever to toxic filtrates
of streptococcus. Am. Jour. Dis. Child., 37:98-111, (Jan.)
1929.

15. Wilson, M. G. : Rheumatic fever; childhood rheumatism.

Preventive Medicine, 8:7-20, (April) 1938.

16. Woofter, A. C. : Preliminary survey on the relation of
physical defects to scholastic standing. W. Virginia Med.
Jour., 35:413-415, (Sept.) 1939.

General References

Coburn, A. F. : The Factor of Infection in the Rheumatic

State. Baltimore: Williams and Wilkins, 1931.

Wilson, M. G. : Rheumatic Fever. New York: The Common-

wealth Fund, 1940.

MICHIGAN'S SANATORIA

Citizens o£ Michigan may well be proud of their
tuberculosis record — for this state is now among the
leaders in case-finding, treatment and hospitalization
for the tuberculous.

Individual effort and organized campaigns have
helped to reduce the state tuberculosis death rate al-
most 60% since the beginning of the century. For 34
years the Michigan Tuberculosis Association has been
carrying on educational and actual case-finding pro-
grams. At the present time the Michigan Sanatorium
Association is voluntarily conducting a survey in order
to improve the already high standards of tuberculosis
treatment in state approved sanatoriums. Through ef-
fective laws, the legislature has been able to make
hospitalization and treatment available to r’ch and poor
alike.

Figuratively, Michigan is now on the last lap. Ac-
tually, there is much to be done. Last year 6,119 active
cases of tuberculosis were reported in the state, and
it is estimated that there were around 12,000 unknown
cases. The goal of tuberculosis care is “hospitalization
and treatment for every known case.” — Health, Jan.-
Feb., 1941.

March, 1941

211

CLINICO-PATHOLOGICAL CONFERENCE

Clinico-PathDlngiGal

Conference

Detroit Receiving Hospital
January 16, 1941

P. T., a colored man, thirty-eight years of age, was
admitted to the hospital on July 19, complaining of
weakness and cough of three weeks’ duration.

Present Illness. — This patient had had a number of
previous admissions to Receiving Hospital for the treat-
ment of his diabetes which was known to have existed
for five years. He had not followed his diet and insulin
requirements consistently partly because of financial dif-
ficulties. His last previous admission was in May, 1940,
when he had experienced increased thirst, polyuria,
and loss of weight apparently because he had not
been able to follow his diet. He was discharged from
the hospital on a daily dosage of 40 units of protamine
insulin and a diet containing 150 grams of carbohy-
drate, 75 grams of protein and 120 grams of fat. He
left without the sanction of his doctor and the diabetes
was not completely controlled. He continued to feel
poorly and was unable to work. About three weeks
before his present admission be began to notice marked
fatigue on any exertion, had drenching night sweats
and felt feverish during the day. A week later a
cough which he had paid no' attention to previously
become more marked and productive of moderate
amounts of greenish mucopurulent sputum. He did
not complain of polyuria, polyphagia, polydypsia, or
drowsiness.

Pcist History. — General health good. No serious ill-
nesses. No history of venereal disease. No operations.
Blood pressure of 190/130 recorded on admission in
May, 1940. Review of history by systems incomplete.

Familial History, Marital History and Occupational
History : Not remarkable.

Physical Examination. — Revealed a slender, emaciated,
acutely ill, colored male. Mental state clear. Tempera-
ture 102°, pulse 120, respirations 25. Eyes : ocular pupils
equal and regular reacting promptly to light and upon
accommodation. Ocular fundi showed moderate nar-
rowing and sclerosis of the retinal arterioles. No
hemorrhages or exudates. Ears, nose and throat ;
not remarkable. Neck: no cervical rigidity. No en-
largement of thyroid gland. No cervical or other
lymphadenopathy. Lungs : dullness to percussion over
the right apex anteriorly and po'steriorly. Bronchial
breathing, increased tactile fremitus, bronchophony and
numerous medium crepitant rales over this area. Scat-
tered crepitant rales over remainder of right lung field
and at left base. Heart : apical impulse visible and
palpable in fifth intercostal space in the mid-clavicular
line. Heart sounds of good quality without audible
murmurs. Blood pressure 140/90. Abdomen : liver,
spleen and kidneys not palpable. No masses, tender-
ness or rigidity. Extremities : radial arteries slightly

thickened. Tendon reflexes normal. Rectal and geni- !
talia : negative. \

Laboratory Tests. — See table. Other Laboratory Eind-
ings : urinalysis : specific gravity quantity not sufficient,
sugar O, albumin trace ; sediment — one leukocyte per
h.p.f. Blood: Hemoglobin 9.5 grams; erythroctyes 3.46
millions ; leukocytes 6,600 ; neutrophiles 72 per cent,
filamented 42 per cent, non-filamented 30 per cent,
eosinophiles 1 per cent, lymphocytes 26 per cent, mono-
nuclears 1 per cent. Kline test negative. Roentgeno-
grams to be repcvrted.

Clinical Course. — Patient’s temperature remained >
consistently elevated, rising gradually to a peak of
105°. The pulse rate ranged between 110 and 130.
Respirations gradually rose from 25 to 35. On the ;
morning of July 20, patient had what was apparently
a hypoglycemic reaction for which 50 c.c. of 50 per cent
glucose were given intravenously. Another similar
attack occurred at 8:00 p. m. on July 20. At 2:00 a. m. i
on July 21 patient was seen in a tonic convulsion and !
unconscious mental state which responded within four
minutes to the intravenous injection of 40 c.c. of 50 ,
per cent glucose. Again at 4 :30 a. m. he relapsed into a
stuporous condition which again responded quickly to j
50 per cent glucose. Because of this recurrence he was |
given 1,000 c.c. of 10 per cent glucose intravenously [
slowly. At 9:00 a. m. and 11 :00 a. m. less severe hypo- I
glycemic symptoms occurred which were controlled by
oral administration of coma feedings. At 3 :30 p. m.,
the patient had an attack consisting of clonic con-
vulsion of all extremities with twitchings of the facial
muscles, accompanied by lack of response to external
stimuli, groaning and turning of the head to the left. 1
The skin was described as hot and moist. He remained
unconscious for about thirty minutes following which
he gradually regained consciousness. Similar uncon- i
scions episodes occurred at 6 :45 p. m. and again
at 2 :00 a. m. on July 22. During the afternoon on July j
22, another similar episode occurred the patient re- I
spending again to intravenous glucose. At 6 :00 p. m.
while the patient was talking to his wife he had a
sudden convulsion and expired in a few minutes.

Discussion

Dr. Richard McKean ; This patient had a
number of previous admissions to this hospital,
and there is no question that he had true diabetes
mellitus. We have all of the evidence necessar}'
to establish an undoubted diagnosis of that par-
ticular condition. The story of his present illness i
indicates that he has developed a complicating
disease, but does not give any definite information
concerning its nature. Cough is a prominent fea-
ture of his illness, but the type of sputum is not
characteristic enough to be of any help in deciding
what the source of this is. Likewise, it was ap- :
parently impossible to get an accurate history of

Jour. M.S.M.S.

212

CLIXICO-PATHOLOGICAL CONFERENCE

Date

Time

Insulin

Blood

CO2

Urine

Diacetic

Feedings

Sugar

Sugar

Acetone

7/19/40

4:30 p.m.

blue

*coma feeding

9:00 p.m.

blue

coma feeding

7/20/40

7 :00 a.m.
7 :30 a.m.
9:30 a.m.

U 40 (prot.)

34

58 vol. %

green

negative

50 c.c, 50% glu. IV’

11:30 a.m.

green

*diet

4:30 p.m.

green

diet

7 :00 p.m.

50 c.c. 50% ghi. IV

8:00 p.m.

green

coma feeding

7/21/40

2:30 a.m.

20

52 vol. %

40 c.c. 50% glu. IV

4:30 a.m.

U XV (reg.)

\ 50 c.c. 50% glu. IV
i 100 c.c. 10% glu. IV

7 :30 a.m.

yellow

negative

diet

9:00 a.m.

coma feeding

11:00 a.m.

66.2

coma feeding

11:30 a.m.

yellow

diet

3:30 p.m.

26

50 c.c. 50% glu. IV

4:00 p.m.

coma feeding

4:30 p.m.

unable to
obtain spec.

diet

7 :00 p.m.

j 100 c.c. 50% glu. IV
( coma feeding

8:30 p.m.

yellow

coma feeding

2:00 a.m.

green

100 c.c. 50% glu. IV

4:00 a.m.

each coma feeding

6:00 a.m.

each coma feeding

7/22/40

7 :30 a.m.
8:30 a.m.

green

negative

coma feeding

11:30 a.m.

orange

diet

3:30 p.m.

18.0

50 c.c. 50% glu. I\"

4:00 p.m.

( 50 c.c. 50% glu. IV

/ 1000 c.c. 10% glu. IV

4:30 p.m.

unable to
obtain spec.

6:00 p.m.

Expired

the diet which he had been following, or to know
whether he had been taking insulin regularly.
This leaves us in the dark as far as being able
to estimate how well or how poorly his diabetes
may have been controlled. However, judging
from the lack of polyuria, polyphagia, polydipsia
and drowsiness it was not a diabetic acidotic state
which caused his entr}' on this admission.

The examination of the ocular fundi bear out
the previous finding of hypertensive vascular
disease. The chest findings indicate a consolida-
tion of the left upper lobe which could be either
a tuberculous process, possibly with cavitation,
or an apical lobar pneumonia. The considerable
drop in blood pressure from a previous reading
of 190/130 to 140/90 may be merely secondar}'
to his general state of malnutrition but may,
on the other hand speak for more than meets
the eye. Aside from the laborator}* work per-
taining to blood sugar and urine, the most signifi-
cant finding is the absence of leucocytosis. Al-

though we have had a number of cases of pneu-
mococcic pneumonia with perfectly normal leu-
cocyte counts, and some with frank leucopenia,
such a definite lobar involvement as was found in
this case is usually accompanied by leukocHosis.
Therefore, this is a point in favor of pulmonary
tuberculosis, and combined with a history of a
chronic cough and night sweats, in a colored pa-
tient with diabetes makes this the most probable
cause of his pulmonan’ disease.

The low blood sugar levels, the absence of ap-
preciable glycosuria in spite of the small amount
of insulin and the large amounts of dextrose
which were given intravenously and orally to
this patient represent just the opposite effects
from what we would expect in a moderately se-
vere diabetic. The explanation of this paradox is
the chief problem in this case. I have never seen
this occur in the course of combined diabetes and
pulmonary tuberculosis, although we have fol-
lowed some 220 cases of this type at Herman

March, 1941

213

CLINICO-PATHOLOGICAL CONFERENCE

Kiefer Hospital during the past ten years. Usual-
ly their diabetes becomes more severe because
of the accompanying infection. Occasionally, as
in any diabetic, failure to eat while continuing to
take insulin will result in hypoglycemic reac-
tions. However, this man, who in thirty-six hours
had no insulin, kept on having steadily decreas-
ing blood sugar levels down to 18.5 mg. per cent.

What are some of the causes of hypoglycemia
which we might consider ? First, there is true
hyperinsulinism, which can be caused either by
overdosage of parenterally injected insulin, or by
diffuse hyperplasia, an adenoma, or a carcinoma
of the islet tissue of the pancreas. These path-
ologic states represent islet tissue and function
gone wild, producing more insulin than is needed
for the normal metabolic processes. This, to my
knowledge, has never occurred in patients who
were previously diabetic, presumably with hypo-
functioning islet tissue, and therefore is unlikely
in this case. All other types of hypoglycemia
are not due to hyperinsulinism, unless one as-
sumes that hyperfunction may occur in the ab-
sence of pathologic changes in the pancreas.
Hepatic disease of various types including toxic
cirrhosis, diffuse carcinomatous involvement, the
so-called fatty metamorphosis of the liver, or
in fact, any disease which affects widely the liver
parenchyma may be accompanied by hypogly-
cemia. The explanation of this type of hypogly-
cemia is to be found in the disturbance of a nor-
mal physiologic mechanism through which the
blood sugar is controlled. Normally, when there
is an increased demand for glucose and a tend-
ency for the blood sugar to fall, the conversion
into glucose of glycogen stored in the liver is
accelerated. This acceleration is caused by a
reflex stimulation of the splanchnic nerves which
act on the liver directly and also indirectly by
the production of increased amounts of adren-
alin. If the store of glycogen in the liver is de-
pleted by disease this mechanism cannot operate
and hypoglycemia may result. A valuable
aid in excluding this type of hypoglycemia
is the subcutaneous injection of adrenalin.
This will cause a prompt rise in blood sugar
if the liver stores of glycogen are normal.
In this case there is no evidence of hepatic dis-
ease— jaundice is absent, and the liver is not
demonstrably changed in size. There was ap-
parently not sufficient opportunity to study liver
function. Dr. Max Pinner, formerly the Path-

ologist at Herman Kiefer Hospital, has frequent- i
ly found fatty livers in patients dying from
tuberculosis. A similar type of involvement is
occasionally seen in diabetes, especially when it ;
is not well controlled. Such a change may pos- o:
sibly be present in this case. Diffuse carcin- \
omatous involvement could be present without -
jaundice, but such a diagnosis in a patient of
this age without other evidence of carcinoma c
would be sheer speculation. Hemochromatosis -
should be mentioned although the lack of hepatic :
enlargement as well as the absence of abnormal r
pigmentation of the skin tend to exclude this dis- ;
ease. A more likely condition would be a chronic
hepatitis or cirrhosis.

Another cause of hypoglycemia is the absence '
or diminution of the internal secretion of the
anterior pituitary, the thyroid, or the cortex of ’
the adrenal glands. These products normally op-
pose the action of insulin and their lack may
lead to hypoglycemia even when the insulin
production is normal. Basophilic adenomas of
the pituitary are often accompanied by hyper-
tension, hyperglycemia and glycosuria, the two
latter being due to an excess of the diabetogenic
hormone. The exact mechanism of the effect of
this hormone is not known, although there is
good evidence that it may exert its effect through
the adrenal cortex. It is possible to hypothecate
the development of hypopituitarism later in the
course of this disease due to destruction of nor-
mal pituitary substance and thus to explain this
patient’s previous hypertension and diabetes with
the later fall in blood pressure and the appear-
ance of hypoglycemia. However, he did not
show at any time the characteristic obesity of
patients having basophilic pituitary adenomas,
his diabetes was more severe than that usually
seen in this condition and a subsequent hypopitui-
tarism, while it occurs commonly in other pitui-
tary tumors, must be either non-existent or very
unusual in Cushing’s disease because of the usual
small size of basophilic adenomas. Therefore, if
a pituitary lesion is present, it is either one of
the other types of pituitary tumors, or destruc-
tion of the pituitary from hemorrhage or unex-
plained atrophy. I have never seen hypothyroid-
ism produce hypoglycemia of this severity. Fur-
thermore, there was no evidence of myxedema.
This patient might be considered to be a candi-
date for Addison’s disease. The chief thing
against adrenal insufficiency as a factor in his

214

Tour. M.S.M.S.

CLINICO-PATHOLOGICAL CONFERENCE

J

hypoglycemia is the blood pressure reading of
140/90.

Certain lesions of the central nervous system
may show glycosuria. Although this man had
definite evidence of central nervous system in-
volvement as indicated by convulsive seizures,
these were undoubtedly caused by the hypogly-
cemia rather than being the cause of his disturbed
carbohydrate metabolism. Finally, the most com-
mon cause of hypoglycemia is the so-called func-
tional hypoglycemia. Its etiolog}' is unknown. It
never causes as low blood sugar levels as were
present in this case. Dr. Conn of Ann Arbor has
described beautifully these various types and
their treatment in a recent volume of the Jour-
nal of the American Medical Association.

In summar}% the following diagnosis should be
made in this case ;

1. Diabetes mellitus.

2. Pulmonary tuberculosis, probably with cav-
itation.

3. Hypertensive vascular disease.

4. Cerebral damage secondary to hypogly-
cemia.

5. Hypoglycemia due (in order of probability)
to (a) diffuse hepatic disease, cirrhosis, or fatty
metamorphosis; (b) pituitary insufficiency, from
pituitary" tumor, or atrophy; (c) Addison’s dis-
ease.

Dr. Robert J. Schneck : Doctor McKean has
given a very^ complete discussion of this case,
and I have very little to add. I agree with his
opinion that pulmonary tuberculosis is the best
explanation of the findings in the chest. The sud-
denness of the onset of the hypoglycemia as well
as the absence of findings implicating the liver or
the adrenal glands in my opinion favor a de-
structive lesion of the pituitar}'. A tuberculoma
of the brain associated with the pulmonary tu-
berculosis is a possible cause. A metastatic ab-
scess of the brain secondar}^ to a pulmonary
abscess is a possibility which also should be men-
tioned.

Dr. a. Hazen Price : This series of events
leading to this patient’s death might be recon-
structed as follows : he originally had diabetes
and then developed a respiratory infection. The
latter was probably tuberculous in nature, but
may have been entirely non-tuberculous, or tu-

berculosis with a superimposed acute pulmonary
infection. Also, I believe he probably had some
ty^pe of chronic hepatic disease — chronic hepatitis,
a fatty liver, or, less likely, tuberculosis of the
liver. This may not have been ver}’ extensive,
and the respiratory infection may have acted to
change the state of the liver from one of low
reserve to one with some degree of hepatic insuf-
ficiency, leading to hypoglycemia. In this sense,
the respirator}' infection may have been the
last “straw which broke the camel’s back.” The
lack of evidences or hepatic disease is somewhat
against this course of events. Pituitary or adrenal
insufficiency may have been present. However,
I believe the former explanation best fits this
case.

Dr. jMartix Schaeffer ; I agree with Doctor
McKean’s diagnoses. Amyloid disease of the
liver should be mentioned because of the prob-
ability that he had pulmonar}" tuberculosis. We
have a patient suffering from chronic pancreatitis
who developed rather severe hypoglycemia each
time he experienced a flare-up of this condition.

Roentgenologic Findings

Roentgenogram of the chest taken July 20, 1940
showed consolidation throughout the entire right upper
lobe, most of the right lower and the mid-portion of
the left lung field. The remainder of the lung fields
were clear. The costophrenic sinuses were clear.

The appearance was that of a rapidly advancing bi-
lateral tuberculosis.

Pathologic Findings

Final Diagnosis. — (1) Tuberculous pneumonia, right
upper lobe; (2) pancreatic fibrosis secondar}’ to cal-
culous obstruction of pancreatic duct.

The pituitar}', liver, thyroid and adrenals were nor-
mal. The r'ght lung weighed 1,240 grams and the left
lung 400 grams. The right upper lobe was completely
consolidated. The microscopic picture was that of
acute tuberculosis with coalescence of tubercles, ex-
tensive necrosis and leukocytic exudation.

The pancreas was uniformly small, extremely firm
and white and measured 2 cm. in diameter. The duct
system was dilated throughout and contained innum-
erable calculi, some ver>' small. One large calculus ob-
structed the duct of Wirsung at its distal extremity.
The pancreas was carefully searched for a neoplasm
and none found. Microscopic examination of the
pancreas revealed extensive fibrosis with fibrous re-
placement of practically all of the acinar tissue as well
as duct dilatation. The islets of Langerhans were con-
spicuously well preserved, many hypertrophied, some
being two and three times the size of normal islets.
It was impossible to prove that there was actual

March, 1941

215

CLINICO-PATHOLOGICAL CONFERENCE

Fig. 1. Photomicrograph of pancreas Fig. 2. Photomicrograph of pancreas Fig. 3. Photomicrograph of lung (X

(X 300). Duct dilatation and almost (X 300). Islet hypertrophy. Apparent 300). Pneumonic consolidation due to

complete fibrous replacement of lobular increase in islet tissue. acute tuberculous infection. Characterized

tissue. by exudation and necrosis.

hyperplasia of islet tissue because of the disturbance
in normal architecture in the pancreas, but the hyper-
trophy of many of the islets would indicate an actual
increase in the total number of islet cells. It seems
fairly reasonable to explain this patient’s hypoglycemia
on the basis of hyperinsulinism.

Dr. Paul H. Noth : The pathologic studies

in this case, as in a definite proportion of cases
of hypoglycemia which have been reported, failed
to disclose a definite cause. It did, however, re-
veal the clinically unsuspected and extremely in-
teresting findings of chronic pancreatitis and pan-
creatic lithiasis, and it also practically excluded a
number of the conditions mentioned in the clin-
ical discussion which was, in the absence of diag-
nostic clinical evidence, necessarily speculative in
nature. The relation of pancreatic lithiasis to
diabetes is probably based upon the presence of
chronic pancreatitis in this condition. A review
of the literature in 1928 resulted in the discovery
of 104 cases with pancreatic calculi. Of seventy
cases with adequate clinical data twenty-four

showed diabetes or glycosuria. Chronic pancre-
atitis without demonstrable calculi is also not
infrequently accompanied by glycosuria. The ob-
servation of the development of diabetes follow-
ing acute pancreatitis is quite infrequent. War-
field, in 1927, reported seven such cases which
he found in the literature and added four of
his own. This was a permanent diabetes in the
five cases in which a subsequent history was ob-
tained. In this case, hepatic, pituitary and adrenal
lesions were absent. The marked destruction of
the acinar tissue recalls the similar case reported
by Barron in 1920, which led Banting to ligate
the pancreatic duct in animals thereby producing
an atrophy of the acinar and duct tissue and dis-
covering another link in the chain of evidence
indicating that the islet tissue is the source of
insulin. There is some inconclusive evidence that
this condition of the pancreas in animals may
lead to hyperplasia of the islet tissue and cause
hyperinsulinism. Such a mechanism may have
been present in this case.

VITAMINS PREFERABLE IN NATURAL FOODS

In the treatment of deficiency states the most important factor is a well-balanced, adequate diet,
which can be supplemented when necessary by preparations containing vitamins and minerals in concen-
trated form. Too much emphasis cannot be placed on giving these substances in the form of natural
foods. Minot says: “Today’s knowledge does not permit us to prescribe with precision the amounts of
the thirty-six or more substances which are required for correct nutrition. To detect deficiencies and
remedy them piecemeal by supplements of manufactured concentrates will not at present solve the
problem. Experience tells us that a mixed diet of natural foodstuffs, one especially rich in milk, green
vegetables, fruit, butter, eggs, and food with ample protein of good biologic value, gives the best results.”
— Citrus Fruits and Health.

216

louR. M.S.M.S.

-K EXPERIMENTAL PROCEDURES A<

Pitiiitrin in Postpartum
Hemorrhage

Tronsabdominal Intra-uterine
Injection

By Donald F. Hoyt, M.D.

Pontiac, Michigan

D. F. Hoyt, M.D.

M.D., University of Michigan, 1925. Mem-
ber of the Staff of Pontiac General Hospital.

Courtesy member of St. Joseph’s Hospital.

Chairman of Record Committee and member
of Advisory Committee of Surgical Section at
Pontiac General Hospital. _ Member of the
Michigan State Medical Society.

■ The surgeon performing a Cesarean Section
commonly injects pituitrin directly into the
wall of the uterus after the baby and placenta
have been delivered. He does this to produce
rapid, complete hemostasis by uterine contrac-
tion. An opposite picture is presented to the
obstetrician once in every 150 labors immediately
postpartum — uterine atony. Intractable hemor-
rhage results. Why does the obstetrician fail
to practice what the surgeon finds so success-
ful?

Method of Injection

Recently, while attending a case of postpartum
hemorrhage due to uterine atony, routine ad-
ministration of oxytocics failed and the idea
above cited occurred. One hand was placed
behind the uterus, pushing the fundus sharply
up against the anterior abdominal wall. Any
trapped intestinal loop would thus be thrust
aside. The bladder was empty or a catheter
would have been inserted to outline its position
for safety. By means of a No. 22 spinal punc-
ture needle 1 c.c. of pitocin was injected in the
uterine muscle, trans-abdominally. The result
was immediate and spectacular. The uterus be-
came exceedingly firm and contracted. The pa-
tient began to groan with the pain of contrac-
tion. Inspections at fifteen-minute intervals
revealed slightly lessened but very effectual con-
stant contraction. In two hours there had been
no additional bleeding. This treatment was pre-

March, 1941

ceded by one transfusion and followed by two.
Trendelenburg position and external heat were
also employed. The patient was discharged in
four days via ambulance to a convalescent hos-
pital. Of some interest is the fact that she
entered the hospital with a hemoglobin of 36
per cent, had postpartum hemorrhage over a
period of seven hours before the treatment just
described was employed, had transfusions total-
ing 1,100 C.C., and was discharged with a hemo-
globin of 42 per cent.

Usual Treatment

In presenting this method of treatment it is
not intended to find a substitute for good con-
servative methods, but rather to replace some
of the more drastic ones hitherto employed in
intractable cases. The therapy of postpartum
hemorrhage may be discussed under four head-
ings:

1. General or supportive measures such as
transfusions, infusions, Trendelenburg position,
heat and uterine massage.

2. Conservative active measures now recog-
nized as being safe and necessary. In the past
fifteen years universal agreement has been
reached in regard to entering the uterus manually
to inspect or remove retained placental tissue.
This is a procedure to be carried out early in
postpartum hemorrhage. In the past five years
the efficacy of ergot preparations intravenously
has been repeatedly demonstrated. Many meth-
ods of bimanual compression of the uterus have
been offered. They merit attention because they
are harmless.

3. However, even with those aids, uterine
atony is uncontrolled in one out of every 150
labors. For this group of cases hot and cold
intra-uterine douches, even cracked ice, and
intra-uterine packs have been used. Discussion
is still rife as to their relative merits, and there
is no agreement as to their efficacy or safety.
Here it is where trans-abdominal intra-uterine
injection of pituitrin should be given its chance.
Of the six writers mentioning this method none

217

PITUITRIN IN POSTPARTUM HEMORRHAGE— HOYT

have reported failure in obtaining vigorous
uterine contraction.

4. Where all these methods fail to control
bleeding the sinister names of Momburg’s tube,
Sehrt’s compressor, Henckel’s clamp, and hyster-
ectomy appear. They are usually pre-mortem
measures.

Intra-uterine Injection

Dr. F. Carreras of Barcelona in 1928 was
the first to mention intra-uterine injection in
postpartum hemorrhage. He told of Dr. Esquire!
having discovered it in Buenos Aires. Torrents
in 1930, also of Barcelona, reported seven cases
in which he used this treatment, six recovering,
one dying of “bulbar embolism.” Torrents
credited Dr. Esquirel. A minor reference in
1933 is the only allusion to it in the medical
literature of this continent. The author J. E.
Green apparently had not heard of its use be-
fore. Rawson, reporting a case in 1935, ob-
viously had not heard nor read of it. Ravina,
and especially Moir, speak most highly of their
personal results with this method. Moir, by
means of a movie camera and a device strapped
to the abdominal wall, showed the speed of
action of oxytocic drugs administered by vari-
ous routes.

References

1. Buxbaum, H., and Udesky, I. C.: Postpartum hemorrhage :
in outpatient obstetrics. Illinois Med. Jour., 70:428-431,
(Nov.) 1936.

2. Carreras, F. : An article describing first use of trans-

abdominal intra-uterine pituitrin. Revista Medica de Barce-
lona, (Aug.) 1928.

3. Corbet, R. M.; Postpartum hemorrhage. Brit. Med. Jour.,
2:438-441, (Aug. 26) 1939.

4. Davin, E. J., and Morris, T. N. : The intravenous use

of basergin in the third stage of labor. Medical Annals
Uist. Columbia, 1-7, (Jan. 9) 1940.

5. Goodman, S. J. : Treatment. Ohio State Med. Jour., 30:

98-99, (Feb.) 1934.

6. Green, J. E. : Postpartum hemorrhage treated in home by

general practitioner. South. Med. Jour., 26:363-366, (April)
1933.

7. Kitchen, D. K.: Management of hemorrhage. Tri-State

Med. Jour., 8:1563-1565, (Dec.) 1935.

8. Kitchen, D. K. : Postpartum atony of uterus. Jour. Ar-

kansas Med. Soc., 33:53-55, (Aug.) 1936.

9. Laird, T.: Control of postpartum hemorrhage. Lancet,

2:998, (Oct. 29) 1938.

10. Moir, C. : Effective methods of using oxytocic drugs in

postpartum hemorrhage. Proc. Roy. Soc. Med., 32:928-929,
(June) 1939.

11. Rawson, W. F. : Intra-uterine pituitary extract in post-

partum hemorrhage. Brit. Med. Jour., 1:1317, (June 29)
1935.

12. Reich, A. M. : Critical analysis of blood loss following

delivery, with special reference to value of ergotrate
(ergonovine malleate). Am. Jour. Obst. and Gynec., 37:224-
233, (Feb.) 1939.

13. Ravina, J. : Intra-uterine injection of posterior pituitary

extract through abdominal wall in therapy of hemorrhage
in third stage. Medecine, 20:309-314, (April) 1939.

14. Smith, W. S.: Incidence (with Dickenson-Pomeroy third

stage technic). New York State Jour. Med., 31:141-149,
(Feb. 1) 1931.

15. Torrents, M. de los S. Salarich: Trans-abdominal intra-

uterine injection of pituitrin in the treatment of postpartum
hemorrhage due to uterine atony. Ars Medica, Barcelona,
(May) 1930.

VDI AN AID TO THE PRIVATE PRACTITIONER

Route

1. Orally

2. Intramuscularly

3. Rectally

4. Intravenously

5. Intra-uterine

Elapsed time before effect
5 to 10 minutes
3^2 minutes
3 to 10 minutes
45 seconds
15 seconds

Although speed is important, the vital point
is that all the drug is introduced directly into the
incompetent organ. Pointedly, at least in the
atonic uterine states, these drugs have a much
more decisive action when injected locally than
when introduced in any other manner.

Summary

Recent years have witnessed important ad-
vances in the treatment of immediate postpartum
hemorrhage. Uterine atony still persists in one
out of 150 labors. Trans-abdominal, intra-
uterine injection of pituitrin is advanced as be-
ing the method of choice in treating these cases.
Eorty-two references were reviewed. Four, all
European, were solely concerned with this
method. Only two others mentioned it, one
being in the American Medical Literature.

Increasing demands on private physicians occasioned
by the national defense program, accents the need for
reliable, current and usable information regarding ve-
nereal disease.

Venereal Disease Information presents a monthly
digest of the important papers on diagnosis, treatment,
pathology, laboratory research, and public health from
the entire world. In addition, it publishes important
special papers and reports by leading scientists. It is
designed to keep both the specialist and the general
practitioner informed of developments in clinical man-
agement and public health control of syphilis, gonor-
rhea, and the venereal diseases.

This medical journal of venereal disease has been
highly recommended by leaders in all fields of public
health. In a rapidly developing and changing field of
medical science, the physician interested in venereal
disease control from the standpoint of differential diag-
nosis and treatment will find VDI an important aid.

Venereal Disease Information is published monthly
by the U. S. Public Health Service. Today it ranks as"
the Government’s “best seller,” with the highest paid
circulation of any Federal publication. It is available
at 50c per year to all physicians.

All orders should be directed to the Superintendent
of documents. Government Printing Office, Washington,
D. C. Subscription fee, 50c per year, in check or money
order, not stamps.

218

Jour. M.S.M.S

Your Responsibility
to

Your Legislator

Michigan’s Legislature of 132 men is in session at
Lansing. These Senators and Representatives come
from every county and district in the state. They will
make laws of direct interest to every doctor of medi-
cine, some touching intimately his very practice of
the healing art.

Already twenty-odd bills affecting physicians in
their professional practice have been introduced into
the Legislature. More will follow. Some of these
proposals are definitely dangerous. They may receive
favorable consideration unless the medical profession
is awake and articulate !

Legislative Bulletins, to keep county society officers
and other key men informed, are mailed weekly by
the State Society. The responsibility for referring
this important information to the legislators must fall
on the family physician and medical friends of the
individual Senator or Representative. No one stationed
in Lansing can do this job, or do it as effectively. It’s
the home town voter who gets the ear of his legislator.

Keep up weekly contacts with your legislator-
friends. Follow through on recommendations from
your State Society’s Legislative Committee, for the
protection of Michigan’s public health and the main-
tenance of the enviable high standard of medical
practice in this state.

President, Michigan State Medical Society.

March, 1941

219

-K EDITORIAL >f

REPORT RHEUMATIC FEVER

“ The present regulations of the Alichigan

State Health Department require that all cases
of rheumatic fever shall be reported. While
there are many men who have done special work
in the “killer of children” and believe it to be
a contagious disease, the question is still debat-
able. However, the conscientious cooperation
of physicians in reporting all of these cases will
give much added light to this question, partic-
ularly at the present time when we are always
interested in medical defense. It is common
knowledge that heart disease was the leading
disability of Michigan men selected for military
service in the First World War, and the largest
number of these dated back to rheumatic fever.

At the request of the subcommittee on Heart
and Degenerative Diseases of the Michigan State
Medical Society, Herman H. Riecker, M.D., of
Ann Arbor has written a short article on “The
Preventive Aspects of Rheumatic Fever” which
will be found on page 208. If every physician
knew and made use of the knowledge contained
in this article a great many of the deaths and
disabilities could be prevented.

Doctor Riecker believes that rheumatic fever
and hemolytic strep infections are more of a
menace now than tuberculosis and since the dis-
eases have similar social and medical implications
he would like to see plans made to use any vacat-
ed space in these hospitals for the care of indi-
gent rheumatic children. He says that recent re-
ports indicate that a great deal more can be done
by isolation of active cases in restoring health
than was formerly thought possible.

Your first step in aiding in the prevention of
rheumatic fever is to report every case.

GENERAL PRACTITIONER

■ In an editorial in The Journal for Septem-
ber, 1940, reference was made to the ideology of
certain groups of specialists in which the general
practitioner was viewed as an agent rather than
employer of the specialist.

The report of the Graduate Commission which
initiated that editorial has also stimulated quite
general comment as to means of protecting the

man in the field from this short-sighted reversed
domination. Some of the “throw-away” type of
journals have made use of the aroused interest
to attack the set-up of the American Medical
Association, pointing out the predominance of
specialists in the controlling positions of the
national organization. It is hard to conceive,
even if this were true, that these men have other
than the best interests of the medical profession
at heart in their deliberations and decisions.
Nevertheless, it is easy to lose sight of the gen-
eral practitioner’s problems. They often seem
trivial to those whose view-points must include
the broad picture of medicine as a whole. Just
as one or two pin holes do not destroy the beauty
of a great picture, enough pin pricks do ir-
reparable damage and something valuable is lost
forever. Therefore, it would seem worthwhile
to repair the pricks in the morale of the profes-
sion as well as to prevent further irritating
practices before a rift may be caused in the uni-
fied profession.

It seems to be a challenge to the officers of
the A.M.A. and the delegates thereto. One pos-
sible remedy might be the inclusion of a prac-
ticing general practitioner on each of the spe-
cialist boards. There are many of these men,
the type of physician who has a broad view-
point of medicine as well as a personal knowl-
edge of the practitioner’s problems. Another
remedy which has been frequently mentioned is
the establishment of a general practice board.
This may have merits though its function seems
rather obscure. Possibly this board, acting as
a liaison group between the profession in general
and the specialists, would render yeoman serv-
ice. The mechanism is not of serious conse-
quence. The result must be accomplished ; that
is, the family physician must be preserved if the
private practice of medicine is to be continued ; to
preserve the family physician he must be en-
couraged in the general practice of medicine.
The specialist must be his advisor and councilor ;
a specialized instrument to be used for the special
case by the general practitioner who should be
educated as to how, and when, and where to use
this instrument.

220

Jour. M.S.M.S.

THE MEDICAL PROFESSION AND SELECTIVE SERVICE

As Michigan physicians progress in the Selec-
tive Service examinations, some interesting facts
about venereal disease are already becoming ap-
parent. The incidence of syphilis among reg-
istrants examined so far is two per cent. Twen-
ty-six thousand Kahn specimens have been rim
at the State Health Department Bureau of Labo-
ratories, and 535 positive specimens have been
reported. We anticipate that this figure of two
per cent may actually decrease a little as time
goes on.

The incidence of gonorrheal infection has been
surprisingly small. We have found among col-
ored registrants, however, that about 80 per cent
of them give a histori’ of having had gonorrhea.

The part that the medical profession of Michi-
gan is playing in Selective Service is becoming
increasingly important as the number of physi-
cians who have accepted appointments with the
Selective Service increases. On February 20
there were 890 doctors assigned to Local Boards
as examining physicians, and 289 serving as
members of Medical Advisory Boards. The ap-
pointment of at least 150 other physicians is
being arranged in Washington at the present
time. Recently a field representative from Na-
tional Selective Service Headquarters at Wash-
ington visited the State and very highly praised
the medical men of Michigan for the part they
are playing in National Defense through the
Selective Service System.

The first call for servicemen in November re-
sulted in the rejection of 19.2 per cent at the
induction centers because of physical reasons.
During Januaiy’^ the rejections dropped four per
cent at the induction centers, and the figures are
not entirely complete as The Journal goes to
press. The leading major cause for rejection
still remains dental deficiencies ; and the second
is faulty vision. More complete figures will be
released as soon as the second call for men is
completed.

[ There is considerable agitation and anxiety
jover the question of deferment of medical and
jdental students. We have had no further infor-
imation from Washington that would change the

!

j March, 1941

original status of the regulations as issued last
September. However, experience has shown us
that few of these men will be called for service
at one time, and that the Local Boards are in-
clined to delay the call of junior and senior
medical students until they have completed the
first year of internship and qualified for their
license to practice medicine. Medical students
are granted deferment by the law until the first
of July, 1941. Beyond that time they must indi-
vidually request deferment on an occupational
basis in Class II as being engaged in an occupa-
tion essential to National Defense. At the pres-
ent time there is little likelihood that the supply
of either interns for the hospitals of Michigan
or students for the medical schools will be seri-
ously interrupted.

Lt. Col. Harold A. Furlong, M.D.

State Medical Officer, Mich. Selective Service.

Cook County

Graduate School of Medicine

(In Affiliation with Cook County Hospital)

Incorporated not for profit
ANNOUNCES CONTINUOUS COURSES

SURGERY — Two Weeks Intensive Course in Surgical
Technique with practice on living tissue, starting
every two weeks. General Courses One, Two,
Three and Six Months; Clinical Courses; Special
Courses. Rectal Surgery every week.

medicine; — Two Weeks Intensive Course starting
June 2nd. One Month Course in Electrocardiog-
raphy and Heart Disease every month, except Aug-
ust and December.

FRACTURES and TRAUMATIC SURGERY — Two
Weeks Intensive Course starting May Sth and
June 30th. Informal Course every week.

GYNECOLOGY — Two Weeks Intensive Course start-
ing April 7th and June 16th. Clinical, Diagpiostic
and Didactic Course every week.

OBSTETRICS — Two Weeks Intensive Course start-
ing April 21. Three Weeks Personal Course start-
ing May 26. Informal Course every week.

OTOLARYNGOLOGY — Two Weeks Intensive Course
starting April 7. Informal and Personal Comses
every week.

OPHTHALMOLOGY — Two Weeks Intensive Course
starting April 21. Informal Course every week.

ROENTGENOLOGY — Courses in X-Ray Interpretation,
Fluoroscopy, Deep X-Ray Therapy every week.

General, Intensive and Special Courses in
All Branches of Medicine, Surgery and
the Specialties.

TEACHING FACULTY — ATTENDING
STAFF OF COOK COUNTY HOSPITAL

Address:

Registrar, 427 South Honore St, Chicago, Illinois

221

MICHIGAN PROGRAM FOR GRADUATES IN MEDICINE

Cooperating Agencies
Michigan State Medical Society
University of Michigan Medical School
Wayne University College of Medicine
Michigan Department of Health

Courses

Ann Arbor and Detroit

All Dates Inclusive

Allergy

Anatomy

Diseases of the Blood and Blood-forming Organs

Diseases of the Genito-Urinary Tract

Diseases of the Heart

Electrocardiographic Diagnosis

Gastroenterology

Laboratory Technic

Nutritional and Endocrine Problems

Ophthalmology and Otolaryngology

Pathology: Special Pathology of Neoplasms

Pathology of the Female Genito-Urinary Organs

Special Pathology of the Eye

Special Pathology of the Ear, Nose, and Throat

Pediatrics

Proctology

Roentgenology

Summer Session Courses

May 12-16

February 12-May 28
(Wednesdays)

May 19-23
April 17, 18 and 19
May 21, 22, and 23
November 3-8
April 28-!May 1
June 30-August 8
November 3-6
April 17-23
June 30-July 11
July 14-25
July 28- August 8
August 11-22
April 28, 29 and 30
April 14, 15 and 16
April 14-19

June 30-August 8 and 22

Extramural Postgraduate Course March 24-April 18

Subjects to be presented

1. The Care of the Injured.

2. The Diagnosis and Treatment of Meningitis.

3. Useful Drugs in Gastro-enterology.

4. Digestive Derangements in Infancy and Childhood

5. The Significance of Albuminuria.

6. Office Gynecology.

7. Clinical Conference. Diagnostic Problems in
Non-Tuberculous Pulmonary Disease.

Ann Arbor — March 27, April 3, April 10, April 17

Battle Creek-Kalamazoo — Alarch 25, April 1, April 8, April 15

Bay City — March 24, March 31, April 7, April 14

Flint — March 26, April 2, April 9, April 16

Grand Rapids — March 27, April 3, April 10, April 17

Lansing-Jackson — March 27, April 3, April 10, April 17

Mount Clemens — March 26, April 2, April 9, April 16

Traverse City-Cadillac-Manistee-Petoskey — March 28, April 4, April 11, April 18
The program will be mailed to physicians in the state within a few days.

For further information, address:

Department of Postgraduate Medicine
1313 Ann Street
Ann Arbor, Michigan

222

Jour. M.S.M.

MICHIGAN MEDICAL SERVICE

This month marks the start of the second year
of operation of Michigan >\Iedical Service. The
I farsightedness of the medical profession in
I Michigan in promoting a wider distribution of
j medical care and better public relations by the
t I organization of this non-profit medical service
I plan has been generally recognized. Committees
or representatives from medical societies in nine
states have come to Michigan to learn what
Michigan Medical Service is doing. Also numer-
ous requests for information from medical
groups throughout the country have been re-
ceived by mail.

The Second Year

The second year of operation of Michigan
Medical Service should be even more successful
because future actions can be based on actual
experiences. With the splendid support of 3,387
participating doctors of medicine — three- fourths
I of the total possible number — it stands to rea-
son that the medical service plan in Michigan
can be developed to a most satisfactory program
for the benefit of patients and doctors alike.

All doctors who have not yet sent in their
Application for Registration with Michigan
Medical Service should do so promptly in order
that the public (not to mention politicians or
I other interested groups) may see that the medi-
' cal profession is united in its endeavor to pro-
j vide a means for persons with limited incomes

I to obtain medical services.

i

(

Medical Service Plan

I During the first year, the enrollment in the
I Medical Service Plan has more than tripled. At
j present, over 5,300 persons are enrolled in this
i complete Medical Service Plan. Already there
i are indications that more and more persons are
: becoming aware of the value of budgeting in ad-
I vance for necessary medical services in the home
I and the office, as well as for medical and surgi-
cal care in the hospital.

In addition to the committees and officers of
Michigan Medical Service, many doctors serving
I on special committees representing the various
I fields of medical practice — the Michigan Derma-

I tological Association, the Michigan Branch of

I

MICHIGAN MEDICAL SERVICE REGISTRATION
HONOR ROLL
(As of February 10, 1941)

100 Per Cent

Barry

Mason

90 to 99 Per Cent

Calhoun

Manistee

Menominee

Monroe

Newaygo

Tuscola

80 to 89 Per Cent

Allegan

Bay — Arenac — Iosco — Gladwin
Chippewa — Mackinac
Clinton

Delta — Schoolcraft
Dickinson — Iron
Gogebic

Gratiot — Isabella — Clare

Hillsdale

Ingham

Kent

Lenawee

Mecosta — Osceola
Midland
Oceana
O.M.C.O.R.O.

Ontonagon
Ottawa
Saginaw
St. Joseph

75 to 79 Per Cent

Branch

Eaton

Houghton — Baraga — Keweenaw

Lapeer

Muskegon

Northern Michigan

Wexford — Kalkaska — Missaukee

the American Urological Society, the Michigan
Association of Roentgenologists and the Detroit
Roentgen Ray Society, the Detroit Ophthalmo-
logical Society, the Michigan Association of Ob-
stetricians and Gynecologists, and the Michigan
Pediatric Society — are all giving generously of
their time to help make the procedures imder
]\Iichigan iMedical Service in accord with the
best medical practices.

Surgical Benefit Plan

The Surgical Benefit Plan has been more
widely accepted by the public than the jMedical
Service Plan, primarily because of the lower
subscription cost. Only a small percentage of
the persons eligible for enrollment are willing to

March, 1941

223

MICHIGAN MEDICAL SERVICE

budget enough to participate in the more com-
plete Medical Service Plan. However, once the
subscribers are enrolled in the Surgical Benefit
Plan, they later desire to pay an additional
amount toi enroll in the more complete Medical
Service Plan. This tendency has become evident
in several groups which were originally enrolled
in the Surgical Benefit Plan and later transferred
to the Medical Service Plan.

Service to Ford Group Ended February 28

The Ford Motor Company, whose employes
enrolled in the Surgical Benefit Plan one year
ago, has decided to arrange for the transfer of
its entire group to an insurance company plan,
beginning March 1, 1941. On and after March
1, Ford employes who sign for the insurance
company plan will be entitled to the usual insur-
ance company schedule of payments for surgical
operations. Michigan Medical Service will pay
for services rendered Ford employes up to Feb-
ruary 28, 1941.

The enrollment of other groups in the Surgical
Benefit Plan is now in excess of 44,000 persons,
representing 223 groups of subscribers, and addi-
tional groups are being enrolled daily. Hence,
the termination of the Ford group will not seri-

ously affect the continuous growth of Michigan
Medical Service. It will mean that doctors of
medicine may no longer have payment made
directly to them for surgical operations rendered
for these several thousand employes. Under the
insurance program, the employes will receive a
specified number of dollars and it will he neces-
sary for the doctor to collect his fee from the
Ford employe direct.

Weekly Payments

With additional cooperation on the part of
doctors of medicine, it will be possible for Michi-
gan Medical Service to make payments to doctors
rendering services for subscribers within a week
after services are completed.

To. do so, it will be necessary for the doctor
to send his Initial Service Report immediately on
the day that his services are first requested by
the subscriber. Upon receipt of this Report, the
subscriber’s eligibility for services can be veri-
fied and necessary records established.

In order that the payment can be made
promptly, it is necessary for the doctor to send
his Monthly Service Report immediately when
services are completed. Please fill in your Re-
port completely so that your payments will not
be delayed.

Fifth Columnist?

224

Jour. M.S.M.S.

SUL^TJUAZOLE

1

■AnjotkeA,

I MPORTANT
CHAPTER

ANTI BACTERIAL
CH EMOTH ERAPY

ULFATHI AZOLE constitutes an additional triumph of chemotherapeutic
research which has proved of great value to clinical medicine.

PNEUMOCOCCUS INFECTIONS . . . Thousands of cases of pneumococcus pneumonia
have responded with dramatic promptness to Sulfathiazole. In comparison
with its pyridine analogue, Sulfathiazole is less likely to cause serious nausea
or to provoke vomiting.

STAPHYLOCOCCUS INFECTIONS . . . With Sulfathiazole, the mortality rote of staphyl-
ococcus septicemia has been strikingly reduced. Thus, in a series of fifteen
reported cases, all of the patients recovered.

GONOCOCCUS INFECTIONS . . . Early cessation of discharge and a high percentage
of cures have been reported. Success has been observed in cases resistant
to other chemotherapeutic agents.

Write for literature
which discusses the in-
dications, dosage and
possible side effects of
Sulfathiazole.

^ ^SUlWTHIAZOlE

WINTHROP

HOW SUPPLIED: Sulfathiazole-Winthrop is supplied in tablets of
0.5 Gm. (7.72 grains); also (primarily for children) in tablets of

0.25 Gm. (3.86 grains).

For preparing test solutions, powder in bottles of 5 Gm.

Wifdltnxifl CHEMICAL COMPANY, INC.

Pharmaceuticals of merit for the physician NEW YORK, N. Y* - WINDSOR, ONT.

79SM

March, 1941

5"ay you saw it in the Journal of the Michigan State Medical Society

225

>f YOU AND YOUR BUSINESS >^

MICHIGAN HOSPITALS AND
MEDICAL PAYMENTS PLAN

■ The agreement re accident cases entered into

by the insurance associations and independent
companies, the State Medical Societ}^ and the
Hospital Association was explained in detail in
the February MSMS Journal (pages 123 to
125, inclusive).

The three forms to be used in connection with
this agreement were published in The Journal.

The Secretary will act as a clearing house from
which Forms 1, 2 and 3 may be obtained. The
cost of the forms in pads of 100 will be fifty
cents ; in pads of 50 the cost will be twenty-five
cents. All three forms are not included in one
pad, so if more than one form is required, be
sure to specify, such as, “a pad of 100 of Form
No. 1, a pad of 50 each of Forms No. 2 and 3,”
et cetera. Cash or postage stamps must ac-
company all orders for blanks. Individual blanks
or copies of Forms 1, 2 and 3, singly or in com-
bination, may be obtained for 5 cents.

Address orders for forms, inquiries, sugges-
tions or complaints for the attention of the Con-
ference Committee to L. Female! Foster, AI.D.,
2020 Olds Tower, Lansing.

THE LAW ON OBSTETRICAL
ENGAGEMENTS

■ When a doctor accepts a patient for confine-
ment, it makes no difference whatever whether
this is a relief patient or a pay patient. The law
requires the same degree of care and skill in
discharging the contract. If a doctor is not
available when labor begins, then the law imposes
upon him the duty of providing a substitute.
The fact that the doctor was called to attend
another patient does not excuse him from the
responsibility, if harm results, from his neglect
of being present during the delivery. This is
quite an important matter, and members of the
profession should fully understand that when a
physician agrees without qualification to qttend
a patient during confinement, he can only dis-
charge that contract by being present or provid-
ing a substitute. The courts have many times

held that it is no excuse that the doctor was en-
gaged with another patient or was making an-
other delivery at the same time. He accepted
the patient and must carr\^ out his contract or
provide competent assistance.

If before the patient enters labor, the doctor
desires to withdraw from the case, then he may
do so by giving the patient reasonable notice so
that another doctor may be secured. This notice,
of course, should be in writing or given orally
in the presence of a witness who will be avail-
able to support the doctor should trouble de-
velop at a later date. A doctor is not released
from his duty under these circumstances by the
mere fact that he is busy with another case. He
has accepted employment and has consented to
bind himself, and the law construes that he is
bound by this contract and must discharge it in
person or by a competent substitute or by giving
timely notice to the patient so that she has suffi-
cient time to secure another doctor.

AN AMBIGUOUS LAW

■ Michigan’s osteopathic practice act (Act 162
of the Public Acts of 1903) is so ambiguous
that osteopaths themselves are not of one mind as
to how far they may practice. Section 6760 states
that the certificate provided in the practice act
“shall entitle the holder thereof to practice oste-
opathy in the state of Michigan in all of its
branches as taught and practiced by the recog-
nized colleges or schools of osteopathy ” So for
example, if a didactic course of neurosurgery
were taught for a week or less in an osteopathic
school, a licensed osteopath in IMichigan thereby
has the right to practice brain surgery on any
and all patients !

A similar ambiguity in the Georgia law has
just been clarified by its Supreme Court which
held in the case of Mabry v. State Board of
Examiners in Optometr)-, 10 S.E. (2d) 740 (Ga.,
1940) : “While the legislature has recognized

osteopathy as one of the healing arts and has
set up a plan for licensing osteopaths, it did not
intend that osteopaths should be permitted to
embrace the field of optometry and other pro-
fessions by adopting the methods of healing

226

Jour. M.S.M.S.

YOU AND YOUR BUSINESS

practiced by such professions, on the theory^ that
such methods are taught and practiced in reput-
able colleges of osteopathy. To construe the
osteopathic practice act as urged by the appellants
would mean that by merely teaching and prac-
ticing ever}’ known science of healing in osteo-
pathic colleges an osteopath would be permitted
to practice without restraint all such methods of
healing. This w’ould nullify every regulatory
statute of the state having for its purpose the
licensing and regulation of the practice of the
various professions of healing authorized by
law.”

The Georgia Supreme Court decided, there-
fore, that osteopaths could practice only oste-
opathy as taught and practiced in osteopathic
schools.

LIABIUTY OF PHYSICIANS
IN MILITARY SERVICE

POTENT WHEN GIVEN

■ Recently the following question was asked :
What is the liability of a physician for rent on
a lease for the time he is serving his country
with the armed forces?

The physicians’ liability is altered to a very
small extent by the fact that he is serving his
country’ in its armed forces. The Soldiers’ and
Sailors’ Relief Act of 1940 (Public No. 861 —
76th Congress) only suspends the enforcement
of civil liabilities in certain cases where the
agreed rent does not exceed $80.00 per month.
In these cases, no eviction or distress shall be
made except on leave of court, but if in the
opinion of the court the ability of the tenant to
pay the agreed rent is not materially affected by
reason of such military service no stay is to be
granted. It may be added that the rental allow-
ance of a First Lieutenant (the lowest rank for
a physician) is $60.00 per month. It thus ap-
pears doubtful if any stay would be granted by
a court for such a case. However, if a stay is
granted, the physician is not completely relieved
of the obligation; it is only postponed.

PLACEMENT BUREAU

ORALLY

iLew TESTICULAR HORMONE

Metandren* exerts true androgenic power
when taken by mouth. It is Ciba’s synthetic, crys-
talline, chemically-pure-methyltestosterone. In
most cases you administer about 4 mg. of
Metandren per os for every mg. of testosterone
propionate which you have been injecting. For
example, you would give four 10-mg. tablets of
Metandren in lieu of one 10-mg. ampule of
testosterone propionate.

Indications for Male and Female — Where the physi-
cian deems injections inadvisable, for patients
who travel, as maintenance therapy in testicular
deficiency of: eunuchism, hypogonadism, im-
potence, the “male climacteric,” prostatism, cryp-
torchidism, certain types of sterility . . . in
menopausal disturbance, excessive uterine bleed-
ing, selected dysmenorrheas, to inhibit post-
partum lactation.

METANDREN IS ISSUED as scored tablets, 10 mg. each,
in boxes of 15 and bottles of 30 and 100 tablets.

DETAILED LITERATURE UPON REQUEST

‘Trade Mark Reg. U. S. Pat. OfiF. Word "Metandren” identifies
the product as 17-methyltestosterone of Ciba’s manufacture.

■ Opportunities for practice are said to exist
in several localities of Michigan.

For detailed information write the Placement
Bureau, MSMS, 2020 Olds Tower, Lansing,
Michigan.

CIBA PHARMACEUTICAL PRODUCTS, IlVC.

SUHIHIIT, NEW JERSEY

!March, 1941

Yay you saza it in the Journal of the Michigaii State Medical Society

227

Woman^s Auxiliary

Bay County

The Bay County Woman’s Auxiliary held its main
meeting of the year on January 8 at the Mercy Hos-
pital and Nurses Home. Dinner was served to a group
of members and their husbands in compliment to Dr.
Frank H. Power, of Ann Arbor, who was our lec-
turer for the evening. ^

Dr. Power gave an illustrated lecture on Cancer,
which was very interesting and informative. The pub-
lic was invited to attend the lecture and a capacity
crowd attended.

Mrs. J. N. Asline,
Corresponding Secretary.

Genesee County

The regular monthly meeting of the Woman s Auxil-
iary of the Genesee County Medical Society was held
on January 22 at 12:30 p. m. at the Y. W. C. A. with
about 65 members present. Mrs. George Curry was
chairman in charge with an assisting committee com-
posed of Mrs. George Conover, Mrs. F. E. Reeder, Mrs.
Arthur Kretchmar. The regular meeting was preceded
by the board meeting at 11 :45 a. m.

A change of date for both the February and March
meetings was announced by the board. At the Febru-
ary meeting the program was in charge of Mrs. Clif-
ford Colwell, who presented an Interior Decorator.
The regular March meeting will be held on the third
Tuesday, March 18, at Hurley Hospital.

Bernice R. Wright, Chairman.

of the October and November meetings and Mrs. An-
drew Payne gave the treasurer’s report.

After a very short meeting the evening was spent
playing bridge, prizes going to Mrs. George Baker,
Mrs. William Meade, Mrs. P. A. Scheurer and Mrs.
Harold Dold. The committee consisted of Mrs. W. B.
Anderson, Mrs. H. W. Porter, Mrs. W. L. Faust, Mrs.
W. L. Finton, Mrs. F. J. Gibson, Mrs. R. J. Hanna,
Mrs. W. H. Lake, Mrs. E. G. Wilson, Mrs. L. F.
Thalner and Mrs. William Meade.

Saginaw County

The Saginaw County Auxiliary was indeed compli-
mented on Tuesday evening, January 21, when Dr. and
Mrs. Paul R. Urmston of Bay City visited the group.
The meeting was held at the home of Mrs. Louis D.
Gomon, Edgewood Road, Saginaw.

Dr. Urmston, president of the Michigan State Medical
Society, spoke on the “Political and Economic Side
of the Practice of Medicine.’’ He also reviewed the
program of the NYA, which has been approved by
the State Society.

Yarn for Red Cross knitting was distributed to
members and during a short business meeting it was
decided to assist the Social Agencies in supplying
Cod Liver Oil to indigent children.

Mrs. Fred Pietz was chairman of the social hour
which followed. Dainty refreshments were served
with the following committee assisting : Mrs. E. P.

Richter, Mrs. F. E. Luger, Mrs. E. G. Tiedke, Mrs.
J. H. Curts, Mrs. C. W. Cory, Mrs. H. A. Phillips
and Mrs. R. I. Lurie.

Grand Traverse-Leelanau-Benzie

The Woman’s Medical Auxiliary, having been or-
ganized a little over a year, is still in the embryonic
stage, with a membership of twenty-one. We have
held our meetings on the same evenings as the Medical
Society, at the Central Michigan Children’s Clinic,
Traverse City.

Following our business sessions we have made sup-
plies for the James Decker Munson Hospital, Traverse
City. On two occasions we have had physicians speak
to us, the Public Health Physician being one. who
spoke on the Public Health P-ogram in the counties.
The other spoke on pending bills in the Legislature in
regard to medicine.

Last October, after the infantile paralysis epidemic
occurred in Northern Michigan, we decided to launch
a drive for funds for an iron lung to be donated
to Munson Hospital. The drive was very successful,
the citizens and organizations of the cornmunity re-
sponding in a most generous manner, with the re-
sult that we have purchased the iron lung, costing
$1,500; also an infant respirator for the hospital, at
a cost of $375, and we still have funds to apply on
a new project.

We have enjoyed our work and hope to accom-
plish greater things in the future.

Marjorie W. Thompson,
Corresponding Secretary.

Jackson County

The regular monthl}' meeting of the Jackson County
Medical Auxiliary was held January 21 at the Hayes
Hotel. Dinner was served to eighteen members.

The business meeting was opened by the president,
Mrs G R. Bullen. Mrs. Balconi read the minutes

St. Clair County

At a dinner meeting of the Auxiliary to the St. Clair
Medical Society held January 14 at the Chateau,
members voted to meet Fridays from 1 to 4:30 p. m. at
the Red Cross Headquarters to make surgical dress-
ings.

Mrs. D. H. Burley, Almont, described the work
of the Auxiliary of the Lapeer County Medical So-
ciety. Mrs. B. C. Clyne, Yale, and Mrs. W. H.
Boughner, Algonac, were members from out of to^\^l
at the meeting. A round table discussion followed Mrs.
Burley’s talk. Mrs. M’. A. Schaeffer, vice president,
conducted the business meeting.

Ernestine F. Treadgold,
Press Chairman.

Wayne County

On January 10, 1941, the Wayne Countj- Woman’s
Auxiliary met at the Woman’s City Club for luncheon
preceding the regular meeting.

Dr. Bruce H. Douglas was the guest speaker who
addressed the group on the “Prevention and Control
of Tuberculosis in Detroit.” Dr. Douglas’ descrip-
tion of modern methods used in the control of this
disease was both interesting and instructive. The
statistics which he gave, showing the steadj’ decline
in the number of cases in the Detroit area, were very
encouraging, but showed the tremendous amount of
work yet to be done in stamping out this scourge.

At the close of the program there was a short
business meeting, at which the president, Mrs. Fred-
erick G. Buesser, presided.

Margaret J. Wallace,
Press Chairman.

Jour. M.S.M.S.

228

WEHENKEL SANATORICM

A MODERN, comfortable sanatorium adequately equipped for all types of medical and
surgical treatment of tuberculosis. Sanatorium easily reached by way of Michigan
Highway Number 53 to Comer of Gates St., Romeo, Michigan.

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Sanitarium Hotel Accommodations

March, 1941

Say you sati’ it in the Journal of the Michigan State Medical Society

229

-K

MICHIGAN’S DEPARTMENT OF HEALTH

HENRY A. MOYER, M.D., Commissioner, Lansing, Michigan

NEW BUREAU OF TUBERCULOSIS

Dr. George A. Sherman of Pontiac has been ap-
pointed director of the Bureau of Tuberculosis, newly
created bureau in the Michigan Department of Health.
Previously, tuberculosis control has been one of the
activities of the Bureau of Epidemiology.

In order to take over the tuberculosis work for
the State Department of Health, Dr. Sherman re-
signed as director of the Oakland County Sanatorium,
250-bed institution which is the largest of the thirty-
three county tuberculosis sanatoriums in the state.

“Organization of the new bureau is a step in a concentrated
attack on tuberculosis which the State Department of Health
will feature from now on,” Commissioner Moyer said. “By
intensifying finding of cases by x-ray and other methods, and
by cooperating with other organizations having the same aim,
we shall be able to bring more persons under early treatment.
That will cut the cost to the state and to counties, and will
mean more cures.

“I have received from physicians and others hearty approval
of the appointment of Dr Sherman. We are fortunate in get-
ting him.”

Dr. Sherman is forty-four years old, a diplomate
of the American Board of Internal Medicine, and is
a recognized tuberculosis specialist. He is a fellow
of the American College of Physicians, a member of
the Michigan Association of Roentgenologists, and a
member of the Michigan State Medical Society. In
1939-4B he was a member of the Council of the Michi-
gan State Medical Society. In 1939 he served as
president of the Oakland County Medical Society.

Dr. Sherman is president of the Michigan Tubercu-
losis Association, and a past president of the Michi-
gan Trudeau Society and the Michigan Sanatorium
Association.

After graduation from McGill University, Faculty of
Medicine, Dr. Sherman was instructor in internal medi-
cine at the University Hospital, University of Michi-
gan. He was medical director of the tuberculosis divi-
sion of the hospital from 1926 to 1928. He entered
private practice at Pontiac in 1929 and became medical
director of the Oakland County Sanatorium in 1933.

Physicians' Service Laboratory

608 Kales Bldg. — 76 W. Adams Ave.
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Blood Count

Complete Blood Chemistry
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Basal Metabolic Rate
Autogenous Vaccines

Complete Urine Examina-
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Smear Examination
Darkfield Examination

All types of mailing containers supplied.

Reports by mail, phone and telegraph.

Write for further information and prices.

LOBAR PNEUMONIA LESS

Lobar pneumonia cases reported so far this season
have run far below ten-year average figures. The com-
parisons follow:

Reported Cases of Lobar Pneumonia

1940-41 1939-40 Ten-year

Season Season Average

July 134 92 149

August 84 102 127

September 100 109 153

October 139 147 248

November 203 238 311

December 319 527 517

January 381* 410 619

^Incomplete.

October, November and December totals were the
lowest reported for those months in the previous ten
years, and January cases may also be a record low.

HEALTH UNITS APPRAISED

Appraisals of all county and district health depart-
ments on American Public Health Association stand-
ards are now being made. For a time. Dr. Carl Buck,
field medical director of the A.P.H.A. and Dr. B. G.
Horning, his assistant, will aid in the appraisals. This
will be the first time that all county and district health
departments in the state will have appraisals in the
same year. Dr. E. V. Thiehoff, assistant director of
the Bureau of Local Health Services, will make most
of the appraisals, with the aid of Dr. Buck and Dr.
Horning. Br. Bernard W. Carey and Miss Miriam
Cummings of the Children’s Fund will appraise the
Upper Peninsula departments and the W. K. Kellogg
Foundation will make appraisals in the seven counties
where the Foundation works. The ratings will be
finished by May 1.

PERSONNEL CHANGES

Dr. L. E. Kerr was named director of the Iron
County Health Department by the board of supervisors
January 11, 1941.

AN EDUCATIONAL FOUNDATION dedicated
to scientific study, care and training of child
presenting physical, mental or emotional difficul-
ties.

BANCROFT SCHOOL

September to June

Bancroft Camp

June to September

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Owls Head, Maine. Continued school schedules,
swimming, tennis, golf, etc. Limited Enrolment.
Medical Supervision.

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Guaranteed reliable potency. Our products are laboratory controlled.

Write for general price list.

THE ZEMMER COMPANY MIC 3-41

Chemists to the Medical Profession Oakland Station Pittsburgh, Pa.

230

Jour. M.S.M.S

Say you saiv it in the Journal of the Michigan State Medical Society

-K COUNTY AND PERSONAL ACTIVITIES

100 Per Cent Club ior 1941

Barry

Ingham

Manistee

Muskegon

Oceana

Ontonagon

Tuscola

The above county medical societies have certi-
fied the 1941 dues of 100 per cent of their 1940
membership. A number of other societies have
certified all but a few of their 1940 members.
As soon as these few have paid their 1941 dues
the list of 100 per cent county socities will be
much larger.

For commissioned officers in the medical depart-
ment of the regular navy the next examination will be
held at all large naval hospitals on May 12, 1941, ac-
cording to the Surgeon General of the Un'ted States
Navy.

^ ^ ^

En-abling legislalion to permit the establishment in
Ohio of an organization similar to Afichigan Medical
Service has been introduced in the Ohio Legislature.
It is sponsored by the Ohio State Medical Associa-
tion.

“Plasma Vitamine C and Serum Protein Levels in
IV ound Disruption” is the title of an article appear-
ing in the Journal of the American Medical Associa-
tion, issue of February 22, 1941, by John B. Hartzell,
IM.D., James Winfield, M.D., and J. Logan Irvin,
Ph.D., Detroit.

^ ^ ^

JVni. J. Burns, Executive Secretary of the AISMS,
addressed the Danby Grange near Portland on Thurs-
day, February 13. Mr. Burns also spoke to the E. O.
T. C. Club of Leslie on Tuesday, February 18. His
subject at each meeting was “State-Managed Medicine
vs. Michigan Medical Service.”

^

/. Earl McIntyre, M.D., Lansing, Secretary of the
State Board of Registration in Medicine, was installed
on February 17, 1941, in Chicago, as President of the
Federation of State Medical Boards of the United
States at the annual meeting of the Federation. Con-
gratulations !

^ ^ ^

Physicians wanted by United States Civil Service.
Applications are being accepted by the U. S. Civil Service
Commission, Washington, D. C., for Senior Medical
Officer at $4,600; Medical Officer at $3,800; and As-
sociate Medical Officer at $3,200 per year for service in
the following agencies : Public Health Service, Food
and Drug Administrat’on, Veterans’ Administration,
Civil Aeronautics Administration and Indian Service.

Ukethkiiis

(DUE TO NEISSERIA GONORRHEAE)

SILVER PICRATE

Zit0mpfef0tHhmqv€oftreofm«tamiBterafurewHI beseatupoarequestm

IHN WYETH & BROTHER, INCORPORATED^ PHIIA.

X

C^llyer Pferate^ Wyeth, has
d oonvincm^ record of effec-
tiveness as a locof treat-
ment for acute anterior
urethritis caused by Neis-
serio gdnorrheoe. (1) An
oqueous sofyttqn (0.5 per-
cent) of silver picrate or
water-soiufsie jetty (0.5 per-
cent) are empfo^^Th ^the
treotmenf.

1. Rnight, F., and Shelon-
ski, H. A., ’nTfeatment
of Acute Anterior
Urethritis with Silver
Picrate,” Am. J. Syph.

Gdn. & Ven. pis., 23,

201 (March) 1939.

*Silver‘Pler<tf«, is o definite crystai-
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acid. H is avoilable
crystals and : soluble trituration for
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positoriesf"wah$e-raluble jelly, and
powder for vaginal insufflation.-.^;;.^

M.^RCH, 1941

5ay you saw it in the Journal of the Michigan State Medical Society

231

COUNTY AND PERSONAL ACTIVITIES

Main Entrance

SAWYER SAMTDRIUM
White Daks Farm

Marian, Ohio

For the treatment of
Nervous and Mental Diseases
and Associated Conditions

Licensed for

The Treatment of Mental Diseases
by the Department of Public Welfare
Division of Mental Diseases
of the State of Ohio

Accredited by

The American College of Surgeons
Member of

The American Hospital Association
and

The, Ohio Hospital Association

Housebook giving details, pictures,
and rates will be sent upon request.
Telephone 2140. Address,

SAWYER SAMTDRIUM

White Oaks Farm

Marion, Ohio

Lt. Colonel Harold A. Furlong, M.D., formerly of
Pontiac, head of the Medical Board, State Headquar-
ters of Selective Service, was appointed Administra- I
tor, Michigan Council of Defense, by Governor Mur- I
ray D. Van Wagoner on January 24. Congratulations,
Doctor Furlong !

* * *

At the recent National Conference on Medical Service
in Chicago on February 16 the following from Michigan
were present; P. R. Urmston, M.D., Bay City; Henry
R. Carstens, M.D., and A. S. Brunk, M.D., Detroit;

L. Fernald Foster, M.D., Bay City; Harold A. Miller,

M. D., Lansing; T. S. Conover, M.D., Flint; C. E.

Black, M.D., and J. Earl McIntyre, M.D., Lansing;
E. W. Schnoor, M.D., Grand Rapids ; S. W. Donald-
son, M.D., Ann Arbor ; L. J. Hirschman, M.D., De-
troit; George Le Fevre, M.D., Muskegon; Wm. J.
Burns, Lansing; J. D. Laux and James A. Bechtel,
Detroit. I

* * * i

Doctor, remember your particular friends, the ex-
hibitors, at your annual convention, when you have ,
need of equipment, appliances, medical supplies and
service. Here are ten more of the firms which helped
make the 1940 convention such a success : '

Medical Protective Company, Wheaton, Illinois
Medical Case History Bureau, New York.

Medical Arts Surgicil Supply Company, Grand Rapids.

Mead Johnson & Company, Evansville, Indiana.

M. & R. Dietetic Laboratories, Inc., Columbus, Ohio.

J. B. Lippincott Company, Philadelphia.

Eli Lilly & Company, Indianapolis.

Liebel-Flarsheim, Cincinnati.

Libby, McNeill & Libby, Chicago. I

Lederle Laboratories, Inc., New York.

♦ ♦ ♦

The Northern Tri-State Medical Association will
hold its 1941 Meeting at Tiffin, Ohio, on April 8.
According to E. B. Gillette, M.D., of Toledo, Secretary ■
of the Association, the following outstanding physi- !
cians have been secured for the program which will
begin at 9:00 a. m. in the Tiffin Theater opposite
the Shawhan Hotel ; Frederick P. Yonkman, M.D.,
Detroit; Carl D. Camp, M.D., Ann Arbor; A. D.
Ruedemann, M.D., Cleveland ; E. Perry McCullagh, |
M.D., Cleveland; Roy W. Scott, M.D., Cleveland; |
George M. Curtis, M.D., Columbus, W. D. Gatch, j
M.D., Indianapolis ; Wm. N. Wishard, M.D., Indian- \
apolis, and Elliott P. Joslin, M.D., Boston. Write E.
B. Gillette, M.D., 320 Michigan Street, Toledo, Ohio,
for complete program.

* ♦ *

Clinic Day at St. Mary’s Hospital, Detroit, is sched-
uled for March 20. The program which begins at 9 ;00 '
a. m. includes the following speakers : Roy D. Mc-
Clure, M.D., Detroit; Charles G. Johnson, M.D., De-
troit; Henry K. Ransom, M.D., Ann Arbor; Virgil S.
Counsellor, M.D., Rochester, Minnesota; A. E. Cather-
wood, M.D., Detroit; Harold Henderson, M.D., De-
troit; Frederick A. Coller, M.D., Ann Arbor; Lester
R. Dragstedt, M.D., Chicago; C. Fremont Vale, M.D.,
Detroit ; Warren B. Cooksey, M.D., Detroit ; John B.
Hartzell, M.D., Detroit ; Richard M. Johnson, M.D.,
Detroit ; Edward Ducey, M.D., Detroit ; Robert L.
Schaefer, M.D., Detroit ; Elwood A. Sharp, M.D., De-
troit; J. P. Pratt, M.D., Detroit; George Rieckhoff,

M. D., Detroit; Arthur B. McGraw, M.D., Detroit;
Professor James Reyniers, South Bend, Indiana; Henry

N. Harkins, M.D., Detroit ; D. K. Kitchen, M.D., De^
troit; Walter J. Wilson, Sr., M.D., Detroit; Rev. Hugh
O’Dcwinell, President, Notre Dame University, South
Bend; Henry A. Luce, M.D., Detroit; Mr. Frank Cody,
Detroit ; Allan McDonald, M.D., Detroit ; Edgar Norris,
M.D., Detroit, and Rev. Alphonse M. Schwitalla, S.J.,
St. Louis, Missouri.

232

Say you saw it in the Journal of the Michigan State Medical Society

Jour. M.S.M.S.

COUNTY AND PERSONAL ACTIVITIES

The MSMS Radio Committee advises that the fol-
I lowing Health Talks were broadcast over radio station
CKLW :

Saturday, February, 1, 1941 — “Simple Facts About
How We Hear,” by Wadsworth Warren, M.D., Detroit.

Saturday, February 8, 1941 — “Scarlet Fever,” by
' Franklin H. Top, M.D., Detroit.

Saturday, February 15, 1941 — “Artificial Fever Ther-
3-py,” by Donald Francis, M.D., Detroit.
i Saturday, February 22, 1941 — “The Importance of
3 Prenatal Care,” by Harold Mack, M.D., Detroit.

7 Saturday, March 1, 1941 — “The Value of Anesthesia
: in Surgery and Medicine,” by Norman Bittrick, M.D.,
Detroit.

^ *

i Warning! Check forger at large in Michigan de-
• scribed as 55 to 58 years of age, 5 feet 5 inches to
; 5 feet 8 inches tall, about 185 pounds, smooth talker
■ and fairly well dressed, poses as a state employe and
1 passes small checks in amounts from $9.50 to $12.00,
which are supposedly for expense accounts on the
State Highway, Auditor General and State Conserva-
tion Departments. He is also known to have passed
Township and County checks. He generally purchases
\ a small item and obtains the balance of the check in
1 cash. He has used the following names : Chester

^ Parker, Sr., Peter T. Bogan, George W. Clark, Charles
H. Carlisle and James H. Carter. The name of the
city, the bank, the title of the person signing the
check, the name of the department, etc., is inserted
with a typewriter, and he uses a check protector. If
you have any information on this man, please notify
your local police or the Michigan State Police, East
Lansing.

* ♦ *

Henry F. Vaughan, D.P.H., Detroit, has been named
Professor of Public Health to head the newly cre-
ated School of Public Health at the University of
Michigan. Doctor Vaughan has been special lecturer in
public health administration at the University since
1922. Doctor Vaughan will cooperate in planning a new
building and organization of the new school, which it
is hoped will be ready for operation this fall. The
W. K. Kellogg Foundation and the Rockefeller Foun-
dation are cooperating in the establishment of the
school, each contributing $500,000. Not more than
one-half of the total of $1,0(X),000 thus contributed
may be used for site, building and equipment, the re-
mainder to be spread out over a ten-year period for
expenses of operation. Doctor Vaughan received his
degree in public health from the University of Michigan
in 1916. He has serv^ed as associate professor of public
health at Wayne University from 1915 to 1937 and
since 1937 has been professor of preventive medicine
and public health at Wayne. He has been com-
missioner of health in Detroit since 1918.

^ ^

COUNTY MEDICAL SOCIETY MEETINGS

Bay — Wednesday, January 29 — Bay City — Speaker:
H. A. Pearse, M.D., Detroit — Subject: “Clinical
Gynecology.” — W'^ednesday, February 12 — Bay City —
Program : “Studies in Human Fertility.” — Wednesday,
February 26 — Bay City — Speaker: A. E. Schiller, M.D.,
Detroit — Subject: “The Problem of Dermatitis in

Practice.”

Berrien — Wednesday, February 12 — Niles — Speaker :
Jesse T. Harper, M.D., Detroit — Subject: “Present-

Day Thoughts on the Treatment of Hemorrhoids.”

Calhoun — Tuesday, February* 4 — Battle Creek — Speak-
er : Hobart A. Reimann, M.D., Philadelphia — Subject:
“Treatment of Pneumonia.”

Dickinson-Iron — Thursday, February 6 — Iron Moun-
tain— Subject: “Public Health as it relates to the
Community and Private Practice” in charge of Drs.
Kerr and Place.

March, 1941

There’s no fee
for this
advice

In coses of real thirst, noth-
ing is more welcome to a
welcome guest than a high-
ball made with smooth, mel-
low Johnnie Walker . . .

★

IT’S SESSIBLE TO STICK WITH

Johnnie

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BLENDED SCOTCH WHISKY

Red Label
8 years old

Black Label
12 years old
Both 86.8 proof

CANADA DRY GINGER ALE, INC., NEW YORK, N. Y.
SOLE IMPORTER

Say you saw it in the Journal of the Michigan State Medical Society

233

COUNTY AND PERSONAL ACTIVITIES

HARTZ JELLY — A Non-Irritating Lubricant

Hartz Jelly is a water-soluble, fat-
free lubricant for hands, sounds,
catheters, bougies, cystoscopes, and
other body-entering instruments.

Hartz Jelly contains no petroleum,
soap, starch or other objectionable
materials. It insures an easy in-
troduction with the least inconven-
ience to the patient.

PRICE:

7 FLOORS MEDICAL SUPPLIES $1.50

a dozen tubes

Hillsdale — Thursday, February 20 — Hillsdale — Speak-
er : Charles F. McKhann, M.D., Ann Arbor — Subject;
“The Chronically Undernourished Child” and clinical
conference.

Ingham — Tuesday, February 18 — Lansing — Speaker:
Arthur C. Curtis, M.D., Ann Arbor — Subject: “Chem-
otherapy in Pneumonia.”

lonia-Montcalm — Tuesday, February 11 — Stanton —
Speaker ; C. H. Snyder, M.D., Grand Rapids — Subject ;
“Orthopedic Conditions as seen by the General Practi-
tioner.”

Jackson — Tuesday, February 18 — Jackson — Speaker :
Wm. J. Cassidy, Al.D., Detroit, Color Movies of Ab-
dominal Operations.

Kalamazoo — Tuesday, February 18 — Kalamazoo —
Speaker : Richard Freyberg, M.D., Ann Arbor —

Subject: “Newer Treatments for Arthritis.”

Kent — Tuesday, February 11 — Grand Rapids— Speak-
er : Pearl Kendrick, M.D.

Muskegon — Friday, February 21 — Aluskegon — Speak-
er: Attorney John F. Frederick — Subject: “Intangible
Tax” — Also color motion picture on “Regional Anes-
thesia.”

Oakland — Wednesday, February 5 — Routunda Inn —
Speaker: J. C. Pratt, M.D., Detroit — Subject: “Recent
Advances in Obstetrics and Gynecology.”

Ottawa — Tuesday, February 11 — Grand Haven; —

Speaker : Harold Dykhuizen, M.D., Muskegon —

Subject ; “Role of Urology to Essential Hypertension.”

St. Clair — Tuesday, January 28 — Port Huron — Pro-
gram : Motion picture “The Treatment of Eclampsia.”
Tuesday — February 11 — Port Huron — Speaker: George
Leckie, AI.D., Detroit — Subject: “Tuberculosis of the

Genito-Urinary Tract.” Tuesday — February 25 — Port
Huron — Speaker : H. J. Kullman, M.D., Detroit — Sub-
ject; “Indications for and Value of Gastroscopy.”

St. Joseph — Thursday, February 13 — Sturgis — Speak-
er: Captain Herbert D. Edger of Fort Custer — Subject:
“Military Medicine.”

Shiawassee — Thursday, February- 20 — Owosso — Speak-
er : R. H. Freyberg, M.D., Ann Arbor — Subject:

“Treatment of Chronic Arthritis.”

Washtenaw — Tuesday, February 11 — Ann Arbor —
Speaker; Udo J. Wile, AI.D., Ann Arbor — Subject:
“Pitfalls in the Diagnosis and Treatment of Syphilis.”

■Wayne County — Monday, Ala'rch 3 — Detroit — General
Aleeting — Speaker : Stanley P. Reimann, M.D., Phila-
delphia-Subject: “Normal Intracellular Constituents

in Relation to Growth.” Monday, Alarch 10 — Medical
Aleeting — Speaker; Virgil E. Simpson, AI.D., Louis-
ville— Subject; “The Ph3'sician, the Pharmacist, and
the Pharmacopoeia.” Afonday, Alarch 17 — General Prac-
tice Aleeting — Speaker : R. W. AlcNeah-, AI.D., Chicago
— Subject: “The Mechanics of Inguinal Hernia.” Alon-
day, Alarch 2-1 — Surgical Meeting — Speaker ; Geza de
Takats, AI.D., Chicago — Subject: “Pulmonary Em-

bolism.” Alonday, April 7 — General Aleeting- — Speaker :
John T. Alurphy, AI.D., Toledo — Subject: “Cancer of
the Skin.”- — Annual Hicke\’ Alemorial Lecture.

West Side (Wayne County) — Wednesday-, February
19— Detroit — Speakers : Harry C. Saltzsteiii, AI.D., on
“Terminal Pictures in Alalignancy in Contract with
other Terminal Pictures” and Frank A. Lamberson,
M.D., on “Treatment with Illustrations of Abscesses of
the Face, Neck and Chest,” also motion pictures on
“Studies in Human FertiliU.”

234

Say you sazv it in the Journal of the Michigan State Medical Society

Jour. AI.S.AI.S.

COUNTY AND PERSONAL ACTIVITIES

COUNCIL AND COMMITTEE MEETINGS

1. Tuesday, February 4, 1941 — 11:00 a. m. — Special
meeting of representatives of seven organizations re
afflicted-crippled child law amendments — Hotel Olds,
Lansing.

2. Thursday, February 6, 1941 — 3 :00 p. m. — Executive
Committee of The Council — Hotel Olds, Lansing.

3. Thursday, February 13, 1941 — 3 :00 p. m. — Legisla-
tive Committee — Hotel Olds, Lansing.

4. Monday, February 17, 1941 — 6:30 p. m. — Cancer
Committee — Woman’s League, Ann Arbor.

5. Tuesday, February 18, 1941 — 11:00 a. m. — Special
meeting of representatives of seven organizations re
afflicted-crippled child law amendments — Hotel Olds,
Lansing.

^ ^

McGREGOR CONVALESCENT HOME

The new Convalescent Home of the McGregor
Health Foundation has been opened in Detroit. The
McGregor Health Foundation, a charitable incorpora-
tion of the State of Michigan, was founded seven
years ago by the late Tracy W. McGregor, a well-
known Detroit philanthropist.

Since its inception the Foundation has been working
in the field of convalescent and rest care as an aid
to a more full and rapid recovery from illness. Nu-
merous studies have been made of this problem by the
McGregor Health Foundation and many deserving pa-
tients have been aided by them. A few months ago
a thirty-bed convalescent home was opened by this
Foundation in Detroit, where such useful adjuncts to
recovery from illness as a pleasing and restful environ-
ment, physiotherapy, diversional therapy, dietotherapy,
and expert nursing service, may be provided at a
minimal cost.

The Foundation is managed by a Board of Trustees
composed of physicians, laymen and professional
workers. Michigan is indeed fortunate in having the
McGregor Health Foundation working in this most
important field of medical care.

* *

The February meeting of the Michigan Pathological
Society was held as a joint meeting with the Detroit
X-ray and Radium Society at Henry Ford Hospital
on Saturday, February 8. The Detroit X-ray and Ra-
dium Society had invited members of the Michigan
Radiological Society to be present as guests. Sixty-
four were in attendance.

The afternoon session consisted of demonstrations on
the subject, “Tumors and Cysts of Bone,” and at the
evening session, the cases previously demonstrated
were presented and discussed. Cases were presented by
Drs. Kaump, Frank Hartman, Lester Hoyt, M. O.
Alexander, Howard Doub, John Murphy, and S. M.
Gould.

The next meeting will be held on April 19, in Flint,
Michigan, at the Hurley Hospital, subject to be selected.

March, 1941

I

to any ano®"*

conlalneis- oU.goW

^fficone.

^|^i4ZZ worth while laboratory exam-
inations; including —

Tissue Diagnosis

The Wassermann and Kahn Tests

Blood Chemistry

Bacteriology and Clinical Pathology

Basal Metabolism

Aschheim-Zondek Pregnancy Test

Intravenous Therapy virith rest rooms for
Patients,

Electrocardiograms

Central Laboratory

Oliver W. Lohr, M.D., Director

537 Millard St.

Saginaw

Phone, Dial 2-3893

The pathologist in direction is recognized
by the Council on Medical Education
and Hospitals of the A. M. A.

Say you saw it in the Journal of the Michigan State Medical Society

235

THE DOCTOR'S LIBRARY

LABORATORY APPARATUS

Coors Porcelain
Pyrex Glassware
R. & B. Calibrated Ware
Chemical Thermometers
Hydrometers
Sphygmomanometers

J. J. Baker & Co., C. P. Chemicals
Stains and Reagents
Standard Solutions

• BIOLOGICALS*

Scrums Vaccines

Antitoxins Media

Bacterins Pollens

We are completely equipped and solicit
your inquiry for these lines as well as for
Pharmaceuticals, Chemicals and Supplies,
Surgical Instruments and Dressings,

RUPP & BOWMAN CO.

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“Your tact, cooperation and deter-
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<203

OF

THE dcx:tor’s library

Acknowledgement of all books received will be made in this
column and this will be deemed by us as a full compensation
of those sending them. A selection will be made for review,
as expedient.

DISEASES OF THE DIGESTIVE SYSTEM. Edited by Sid-
ney A. Portis, B.S., M.D., F.A.C.P., Associate Clinical
Professor of Medicine, Rush Medical College of the Uni-
versity of Chicago; Attending Physician, Michael Reese Hos-
pital; Consulting Physician, Cook County Hospital, Chicago.
Illustrated with 176 engravings. Philadelphia: Lea & Fe-

biger, 1941. Price: $10.00.

The reputation of Sidney Portis as a gastro-en-
terologist guarantees the reliability of this textbook.
As he says, “The modern gastro-enterologist must be
thoroughly trained in the laboratory and have a broad
general clinical experience in all branches of internal
medicine.” He has had the assistance of fifty-one con-
tributors, all of whom have established themselves in
their various fields. It is not a very readable book but
provides in textbook fashion a complete story of the
present-day knowledge of gastro-intestinal diseases.
Treatment is especially emphasized, thus enhancing the
value of the volume to the practitioner.

IT IS YOUR LIFE. Keep Healthy — Stay Young — Live Long.
By Max M. Rosenberg, M.D., Member, American Medical
Association and New York County Medical Society. For-
merly in charge of Clinical Laboratory O. P. Dep’t, Beth
Israel Hospital; Clinical Asst. Internal Medicine, Beth
Israel Hospital; Clinical Asst. Pediatrics, Gouveneur Hos-
pital. New York; The Scholastic Book Press, 1940. Price
$2.50.

This is a very sensibly written book of medical ad-
vice to the layman and avoids more than usual the
common fault of lay medical books in mass prescrib-
ing. The language is clear and for the most part re-
liable. In the hands of the average patient it is safe
and should be of educational value.

DIET MA.NUAL. Dietetics Department, Harper Hospital, De-
troit, Michigan. Copyright 1940’.

When a hospital of the standing of Harper Hospital
in Detroit issues a volume of diet lists and instructions
it can be unequivocally accepted as authentic and prac-
tical. A study of this manual bears out this expecta-
tion. All practical consideration seems to be well
covered.

A TEXTBOOK OF CLINICAL PATHOLOGY. Edited by Roy
R. Kracke, Emory University, Georgia, and Francis P.
Parker, Emory University, Georgia. Second Edition. A
William Wood Book. Baltimore: The Williams & Wilkins
Company, 1940. Price: $6.00.

This second edition has been completely revised and
reset. There are many changes due to the addition of
new material, particularly new procedures which have
been introduced in the last two years. A new chapter
on determinations of vitamins and hormones, a re-
written chapter on serological procedures in the diag-
nosis of syphilis, examination of the bone marrow, and
many other additions and revisions of laboratory mate-
rial are included. It is well arranged, accurately writ-
ten and well illustrated with both ordinary and color
plates.

236

Say you saw it in the Journal of the Michigan State Medical Society

Jour. M.S.M.S.

RADON

A

. SE

E D S 1

OR safety and reliability use composite Radon seeds in your
cases requiring interstitial radiation. The Composite Radon
Seed is the only type of metal Radon Seed having smooth,
round, non-cutting ends. In this type of seed, illustrated
here highly magnified. Radon is under gas-tight, leak-proof
seal. Composite Platinum (or Gold) Radon Seeds and
loading-slot instruments for their implantation are available
to you exclusively through us. Inquire and order by mail,
or preferably by telegraph, reversing charges.

THE RADIUM EMANATION CORPORATION

GRAYBAR BLDG. Telephone MO 4-6455 NEW YORK, N. Y.

CLASSOTED ADVERTISING

ADMINISTRATOR’S SALE: The medical equipment
of the late A. H. Burleson, M.D., must be sold. If
interested, write to W. P. Pollard, Administrator,
Olivet, Michigan.

WANTED : Physician for general practice during the
month of June and for an indefinite period thereafter.
Salary guaranteed. Send inquiries to Box 10, Journal
of the M.S.M.S., 2020 Olds Tower, Lansing, Michigan.

WANTED : POSITION AS ASSISTANT to general
surgeon or industrial surgeon or as resident in sur-
gery ; young married physician ; M.D. University of
Alichigan Medical School ; completed internship, as-
sistant residency and residency in surgery at larger
midwestern metropolitan hospital ; conscientious, ex-
cellent references; licensed in Alichigan. Box* 20,
Alichigan State Aledical Society, 2020 Olds Tower,
Lansing, Michigan.

Forms to be used in connection with the Alichi-
gan- Hospital and Medical Payment Plan are
available in pads of 50 and 100 (25c and 50c
respectively). Signify Form 1, 2 or 3 and amount
desired. Address, Secretary, 2020 Olds Tower,
Lansing.

86c out of each $1.00 gross income
used for members benefit

PHYSiaANS CASUALTY ASSOCIATION
PHYSiaANS HEALTH ASSOCIATION

Hospital, Accident, Sickness

INSURANCE

For ethical practitioners exclusively

(52,000 Policies in Force)

LIBERAL HOSPITAL EXPENSE
COVERAGE

For
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sickness

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$9,500,000 PAID FOR CLAIMS

$2(X),000 deposited with State of Nebraska for pro-
tection of our members.

Disability need not be incurred in line of duty — benefits
from the beginning day of disability.

Send for applications, Doctor, to

400 First National Bank Building Omaha, Nebraska

AIarch, 1941

Say you saw it in the Journal of the Michigan State Medical Society

237

Have you received your copy of the
75 page brochure "Citrus Fruits and
Health"? You'll find a wealth of infor-
mative, authoritative material, carefully
compiled and exhaustively treated. Free
on request to members of the medical
profession.

Write for it.

FLORIDA CITRUS COMMISSION

Lakeland Florida

The Mary E. Pogue School

For Exceptional Children

DOCTORS: You may continue to super-
vise the treatment and care of children
you place in our school. Catalogue on
request.

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85 Geneva Road Telephone Wheaton 66

DeNIKE sanitarium, Inc.

Established 1893

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Medical Superintendent

Behind

Mercurochrome

(dibrom-oxymercnri-fiuorescein>sodium)

^ is a background of

Precise manufacturing methods in-
suring uniformity

Controlled laboratory investigation

Chemical and biological control of
each lot produced

Extensive clinical application

Thirteen years’ acceptance by the
Council of Pharmacy and Chem-
istry of the American Medical
Association

A booklet summarizing the impor-
tant reports on Mercurochrome and
describing its various uses will be
sent to physicians on request.

Hynson, Westcott & Dunning, Inc.

BALTIMORE, MARYLAND

IS YOUR DIABETIC RECEIVING A

SQUARE DEAL?

He will, if you advise Square Deal Flour,
rich in minerals, high in vitamins, moder-
ate in food content.

Like a sample, Doctor?

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Box 472

Waukesha, Wisconsin

In Lansing

HOTEL OLDS

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Jour. M.S.M.S

238

Say you saw it in the Journal of the Michigan State Medical Society

In human milk 2/3 of the protein is m true solution, while in cow's
milk only 1/6 of the protein is soluble. During the process em-
ployed in preparing Similac the soluble proteins in cow's milk are
increased to a point approximating the soluble proteins in human
milk. How greatly this improves the digestibility is indicated by
a comparison of the curd (insoluble calcium paracaseinote)
formed by cow's milk, with the soft flocculent curd of Similac.
The softer the curd the shorter the digestive period.'' Similac,
like breast milk, has a consistently zero curd tension.

Espe & Dye — "Effect of Curd Tension on the Digestibility of milk" — Amer. Journal
Diseases of Children — 1932, Vol. 43, p. 62.

Curd

of

Breast

of

Curd

SIMILAC

Curd

of

Cow

Mik

SIMlbAC I

SIMILAR TO
BREAST MILK

L

M&R DIETETIC LABORATORIES, INC.

COLUMBUS, OHIO

April, 1941

Say you saw it in the Journal of the Michigan State Medical Society

257

SELECTIVE SERVICE MEDICAL DEPARTMENT

Announcement has been made of the formation of
three additional Medical Advisory Boards in Detroit.
With the five Medical Advisory Boards already formed,
eight boards will be available to serve the Wayne
County area. The new boards with their hospital head-
quarters and chairman are as follows :

Board No. 20 — Grace Hospital — Milton A. Darling,
M.D.

Board No. 21 — Woman’s Hospital — Roy C. Kings-
wood, M.D.

Board No. 22 — Charles Godwin Jennings Hospital —
Raymond B. Baer, M.D.

Of Michigan’s 679,727 registrants, 287,685 live in

Professional Economics

An ethical, practical plan for bettering
your income from professional services.

Send card or prescription blank for details.

National Discount & Audit Co.

2114 Book Tower, Detroit, Michigan

Representatives in all parts of the United States
and Canada

PftOriSSIOHAlPlIOTICnON

A DOCTOR S.^YS;

“In the future my check stubs
will show that the Medical Protec-
tive fee has gained a position of pre-
eminence over rent, supply and other
hills of the most fundamental im-
portance.”

mm

or

Wayne County. The burden of work on five Medical
Advisory Boards proved considerable. The new boards
with a reshuffling of the jurisdiction of the old boards
ought to materially relieve the situation. Members of I
the Medical Advisory Boards are not paid for their
professional services. Throughout the state these Medi-
cal A-dvisory Boards have been doing an excellent job
advising the Examining Physicians on the doubtful
cases among the selectees.

♦ ♦

The physicians in Michigan have already performed
nearly 40,000 physical examinations. As the quotas of
men increase, the load becomes correspondingly great-
er. In many localities the physicians have formed
examining groups. This has been a very satisfactory j
procedure as it considerably lightens the load on in- I .
dividual physicians and prevents the congestion of small !
offices. The registant is assured of a more careful
consideration of his physical condition by a group of
examiners. Group examinations are encouraged by the
Selective Service wherever local conditions allow.

Recently a decision has come from the National
Headquarters of Selective Service stating that the
same physician or group of physicians may be ap-
pointed examining physician or physicians for more
than one Local Board. A pool of physicians may be
appointed as examining physicians for all the Local
Boards within a community.

* ♦ ♦

In every program there is apt to be a sour note. •
There have been several instances lately where the
press, both in news items and editorially, has criticized »
physicians for their part in the rejection of men at '
the Induction Centers. In most cases such stories were '
published without any clear knowledge of the facts ,
or what was being done to correct the situation. In a !
few instances doctors working for Local Boards have ■ i
been mentioned by name. This, of course, rightfully «
created a terrific reaction among the doctors. The
policy of State Headquarters has been never to re-
lease to the press any information about physicians in
connection with any physical examinations. Local
Boards have also been advised not to release such
information.

It is also the opinion of State Headquarters that
the reason for the rejection of any registrant should
not be disclosed to the press. This is confidential in-
formation and the Local Board should so regard it.
Unfortunately, no one can stop curious reporters from
putting two and two together and producing an article
that hurts. The State Headquarters has investigated
several of these press notices and in each case found
the press wholly unaware of the backfire on the doctor.
Most of the newspapers have sought to justify the
wrong done the selectees who have given up their
jobs, sold their automobiles and received a gala send-
off only to be turned back a day or so later stranded
and humiliated. The wrong to the medical profession
has been unintentional.

* * *

By March 12 the State Health Department Bureau
of Laboratories had performed 39,947 Kahn tests. Of
these 37,612 were negative, 71 reactions were doubt-
ful, and 1,331 specimens were unsatisfactory. Positive
Kahns totalling 933 were reported, a percentage of 2.3.

Arrangements have been completed with the Bureau
of Laboratories to have Kline, Kolmer, or Wasser-
mann reactions performed on the few cases where the
Kahn test may appear to disagree with the clinical
findings.

Harold A. Furlong, M.D.

State Medical Officer,
Selective Service of ]\Iichigan.

Jour. M.S.M.S.

258

Say you saw it in the Journal of the Michigan State Medical Society

nrke J O U M A I

of the Michigan State Medical Society

Issued Monthly Under the Direction of the Council
Volume 40 April, 1941 Number 4

Dermatitis and Eczema

Industrial Aspects*

By John Godwin Downing, M.D.
Boston, Massachusetts

John G. Downing, M.D.

M.D. Harvard Medical School, 1915.
Assistant Professor of Dermatology,
Tufts College Medical School; Derma-
tologist at St. Elisabeth's Hospital, Bos-
ton City Hospital, Beth Israel Hospital,
U. S. Public Health Service. Chair-
man, Section of Dermatology and
Syphilology, A.M.A., 1939-40. Member,
Board of Directors , American Academy
of Dermatology and Syphilology. Mem-
ber, American Dermatological Associa-
tion, New England Dermatological So-
ciety, Society for Investigative Derma-
tology, Industrial Surgeons.

There has never been a time in the history of
the world when the problem of keeping men
fit for industry has been more vitally essential
than in these days of mechanized warfare. In-
dustrial medicine visualized this problem and
since the First World War has made rapid prog-
ress. The importance of preventing industrial
diseases is now recognized, especially protecting
the skilled worker from avoidable hazards, for
the loss of such workers might cripple our na-
tional defense. Industrial dermatoses, which
comprise nearly 60 per cent of all occupational
disease, require special consideration, for accord-
ing to Lane,^^ Osborne and Jordon^^ they can be
prevented. Eight years ago I mentioned the ap-
parent lack of interest in this field in America,®
but there has been a great awakening. The litera-
ture on the subject is now enormous; physicians
are eager for knowledge; industry has realized
the value of safeguarding its employes, and new
states are continually expanding their laws to
embrace occupational dermatoses among compen-
sable diseases.®

^Presented at the Seventy-fifth Annual Meeting of the
Michigan State Medical Society, Detroit, September 26, 1940.

April, 1941

Definition

The committee appointed by the Section of
Dermatology and Syphilology of the American
Medical Association for the study of occupational
dermatoses has defined an occupational dermato-
sis as any pathological condition of the skin for
which occupation was the chief causal or contrib-
utory factor. It may comprise any lesion from a
simple erythema to carcinoma. Occupational der-
matitis (ergodermatitis) under the generic term
“dermatitis venenata” is an inflammatory disease
of the skin characterized by erythema, q^ema,
and vesiculation, and caused by irritants contact-
ed while at work.

Classification

Because of the multiplicity and diversity of
such irritants some effort at classification is
necessary, although no one will be entirely
satisfactory. Classification of industries is of
little value except where dermatoses appear
fairly constantly, for industries change their
processes frequently and use many new com-
binations in these processes.

Classification according to pathological lesions
also has its shortcomings, since nearly all irritants
produce varying degrees of pathological change,
depending upon the intensity and duration of the
application. The most scientific classification is
based on the etiology, the type of agent.® Irri-
tants accordingly may be grouped as follows :

1. Mechanical or physical agents. The derma-
toses caused by this group are the results of heat
or cold, radiation (radium, x-rays), electricity,
mechanical irritation (pressure or friction, cuts
or pricks), and mechanical interference with
bodily functions. The cause and pathological se-
quences of resulting injuries are easily recog-
nized. Mechanical abrasions due to repeated
trauma, harsh detergents, cutting oils, and contact

26.S

DERMATITIS AND ECZEMA— DOWNING

with abrasives and sand are frequent. Lesions
may vary from pigmentation to epithelioma. The
common eruption from mechanical interference
with bodily function is a folliculitis occurring on
the skin of employes contacting oils and silicates.

2. Flowering plants and their products.

(a) Redwood, teak, cocobolo, mahogany, box-
wood, satinwood, Brazilian walnut, chestnut, and
oak are woods which may cause a dermatitis.^^

(b) Extracts and resins including oil of cardiol
from the shell of cashew nuts and lacquers.

(c) Herbaceous plants^® (leaves, flowers, fruits,
or roots.) Asparagus, barley malt, celery, chamo-
mile, flax, grain dusts, hops, pyrethrum, rice,
tobacco, tulips, lettuce, figs, oranges, and lemons
have been proven to be offending agents. It is
interesting to note that it is the outer surface of
lemons and oranges that causes dermatitis.^”

(3) Vital agents. The vegetable kingdom with
its fungi, bacteria, yeast, yeast-like organisms,
and molds, produces serious industrial diseases,
disabling and even fatal, such as folliculitis, fur-
unculosis, streptococcus infections, anthrax, ery-
sipeloid, sporotrichosis, and coccidoidal granulo-
ma. The animal group comprising mites and
spiders causes annoying but trivial eruptions
which respond readily to applications containing
sulphur.

4. Chemical agents. These are so complex
that they defy any exact classification. They may
be divided into: Inorganic compounds, acids,

bases and salts, hydrocarbons and crude coal tar
products, oils, tars and turpentine, and other or-
ganic compounds such as dyes.

A comprehensive list is impossible, for every
conceivable chemical may irritate and produce
a dermatitis in some susceptible individual.
Hence, an occupation should not be condemned
because of a hypersensitive worker; transfer
him rather than abolish a process thereby de-
priving other workers of their livelihood. The
true hazards are soon recognized, such as
arsenic, chrome compounds, chlorinated naph-
thalenes, rubber accelerators, pitch turpentine,
creosote, and bakelite resins.

Dermatitis and Eczema

Ergodermatitis may be also classified according
to the strength of these agents and the length of
exposure as nonsensitization dermatitis (often
called dermatitis artificialis or traumatica) and

sensitization dermatitis. Where the former ends
and the latter begins cannot always be determined.
Nonsensitization dermatitis is caused by a pri-
mary irritant which will affect practically all hu-
man skins. It is a cutaneous disturbance caused
by mechanical or physical agents or primary irri-
tants such as powerful chemicals applied acci-
dentally Or deliberately to the skin. It is charac-
terized by all degrees of inflammation and fre-
quently marked by destruction of all the layers of
the skin and subjacent tissues. The causative
factor is usually recognized and known to the
patient. Noteworthy are self-inflicted eruptions
(dermatitis factitia) produced to invoke sympa-
thy, escape unpleasant duties, or secure compen-
sation or remuneration. These present many bi-
zarre and unnatural patterns and must be con-
sidered in the differential diagnosis of industrial
dermatitis.

Sensitization dermatitis, also called eczema,
contact dermatitis or contact eczema, allergic der-
matitis or allergic eczema, is an inflammation re-
sulting from repeated exposures to substances
innocuous to a normal skin. The condition pre-
sents the usual lesions of dermatitis and is pri-
marily an epithelial reaction with secondary in-
flammatory changes in the corium. The disease
may be specific or nonspecific and is usually ac-
quired in extrauterine life. In occupational ecze-
ma this hypersensitivity is so acquired. A review
of my last 500 cases showed only one with a posi-
tive family history; thirty-three, or 6.6 per cent,
disclosed a previous history of cutaneous eruption
and of these thirteen, or 2.69 per cent, had been
classified as industrial. The onset of a sensitiza-
tion dermatitis is rarely manifested by a sudden
explosion except when a person has contacted a
substance for years, avoided contact with it, and
has a renewed exposure, at which time his sensi-
tization may appear suddenly and explosively.

When a worker presents a dermatitis it is
important both from the viewpoints of eco-
nomics and public health to decide immediately
whether it is occupational or non-occupational
and whether it is contagious or infectious. If
the latter is true, the worker may infect others ;
if the former, the work may affect others. A
knowledge of dermatology will decide the
differentiation of the cutaneous disease, while
an understanding of the work involved may
solve the industrial question.

266

Jour. M.S.M.S.

DERMATITIS AND ECZEMA— DOWNING

Diagnosis

The diagnosis of an occupational dermatitis is
fairly obvious to the trained observer; neverthe-
less a complete physical examination and labora-
tory studies should confirm this diagnosis and
determine if possible any predisposing factors.
The causative factor should be established by
careful history-taking and patch testing. A com-
plete investigation should be made of the family
and personal history. This history-taking should
present a mental picture of the patient’s routine
and his contacts at home, at his pastimes, and at
his work. In industrial pursuits the exact time of
occurrence is especially important. An eruption
appearing immediately after a vacation should
lead one to suspect a non-industrial exposure ; one
appearing at the beginning of a day’s work may
suggest predisposing home factors such as worry
and lack of sleep; one at the end of the day’s
work may indicate excessive fatigue, carelessness
as a result of a rush season, or failure to use pre-
ventive measures. However, the incubation pe-
riod varies so greatly that a keen detective in-
stinct is required to solve these problems. In a
recent survey young untrained workers were
found most susceptible to occupational derma-
titis.^ The introduction of new chemicals or the
treatment of trivial injuries with sensitizing
drugs should be specially investigated. From an
economic point of view the day of the onset will
determine which insurer is liable for a disabling
dermatitis. The cause of industrial contact der-
matitis due to a single sensitization is frequently
solved, but difficulties multiply with the polysen-
sitized person. Painstaking history, however, will
narrow the field of possible irritants and avoid
needless patch testing.

Sites of Eruptions. — The sites of the eruption
of an industrial dermatitis vary according to the
contacts, involving for the most part the exposed
areas such as the hands, arms, and face. Usually
one or more parts are affected. The frequency
with which various parts of the body are affected
is interesting. Nine per cent of 1,004 cases in-
vestigated showed a dermatitis over miscellaneous
regions. The following percentages were ob-
tained from splitting up cases in which more than
one part of the body was affected and distribut-
ing the data anatomically. The hands (47 per
cent) were most frequently involved, followed by
the fingers (13 per cent), forearms (7 per cent),

April, 1941

the feet and legs (each 5 per cent), the face (4
per cent), and the arms (2 per cent). The ini-
tial lesion and its location are important, for a
dermatitis tends to appear at the site of maxi-
mum contact. The average worker in any given
trade shows a fairly consistent history of the site
and character of the onset and presents an erup-
tion which is reasonably characteristic. For ex-
ample, the eruption of the chocolate dipper gen-
erally begins on the right fourth and fifth fingers
and the outer half of the dorsum of the right
hand; the dry fissured appearance of the tips of
the right first, second and third fingers with
separation of the free border of the nails sug-
gests a treer’s dermatitis f hairdressers frequent-
ly exhibit inflammation of the adjacent aspects
of the third and fourth fingers of the left hand
due to holding the hair ; a dishwasher’s hands are
markedly edematous, with maceration of the in-
terdigital spaces ; the baker’s hand has a similar
appearance with the additional factor of an erup-
tion on the lower half of the ulnar area of the
right forerm due to the rotary motion in knead-
ing dough; a tanner presents a hide-like appear-
ance of the forearms ; the bricklayer and mason
show a dry parchment-like skin, with occasion-
ally a folliculitis on the anterior aspect of the
right thigh where the trowel is carried ; the shoe-
dresser discloses a dermatitis of the dorsum of
the first, second, third, and fourth fingers of the
left hand, especially at the tips where he holds
the sponge; a soda-fountain clerk presents paro-
nychias and vesicles on the lateral aspects of the
fingers of both hands, with enlargement of the
epitrochlea and axillary glands ; a shoe-trim-
mer’s dermatitis is present on the dorsum of the
thumb, the radial aspect of the index finger, and
the dorsum of the hand over the first and second
metacarpals ; workers wearing heavy rubber
gloves such as linemen show infiltration and ery-
thema, with characteristic minute papules on the
dorsa of the hands and the anterior aspects of
the wrists ; a machinist or worker who comes in
contact with oil shows a typical folliculitis of the
forearms, hands, and anterior aspects of the
thighs ; a fisherman presents a lichenified erup-
tion over the lower ends of the ulnars, frequently
complicated by small furuncles. An eruption in-
volving the anterior aspect of the body and the
face suggests exposure to steam such as the work
of a kettleminder would entail. An eruption

267

DERMATITIS AND ECZEMA— DOWNING

about the ankles is usually due to trimmings and
floor dust. These characteristic lesions are usual-
ly found in seasoned workers who have gradually
acquired a sensitization which appears slowly and
progressively and which is not due to some re-
cently introduced chemical.

Patch Tests

In dermatology, especially industrial dermatol-
ogy, patch tests are more effective than scratch
or intradermal tests. ^ The technic of such tests
is now familiar to all so that I will merely men-
tion in passing that I now use scotch cellulose tape
bound with narrow strips of adhesive at the edges
to hold the test substance in place. It rarely gives
a reaction such as frequently occurs after ad-
hesive, and allows observation of the test sub-
stance without its removal. Early American ad-
vocates of these tests. Wise, Sulzberger, and
Coca, advised against the use of too strong or too
weak solutions or failure to reproduce the clinical
exposures, the proper test sites, the danger of us-
ing too many closely allied substances, their use
during phases of hyper- and hyposensitivity, and
indiscriminate patch testing with stock collec-
tions.^’^® Experience has taught discretion. These
tests are of value when corroborated by clinical
data, and the amelioration or exacerbation of
symptoms on elimination or reexposure to the
proven irritant. Positive patch tests must produce
a reaction similar to the disease from which the
patient is suffering. Volatile solvents and essen-
tial oils should not be covered with occlusive
dressings, for if a patient is sensitized he may
suffer a marked exacerbation of the existing der-
matitis. A positive reaction after seven days is
usually a sensitivity produced by the test itself.
Patch tests with rubber are prone to be delayed
and show a tendency to flare up for periods of
weeks and months. After the tests have been ap-
plied the patient should remain at the physician’s
office for at least an hour and the test sites should
be scrutinized before dismissal. If negative, the
test may be replaced and the site examined the
following day. Negative sites should be exam-
ined repeatedly. Positive tests do not necessarily
prove that the test substance is the cause of the
dermatitis, nor does a negative test absolve it.'
Recently I read an article in an industrial maga-
zine, by an industrial physician, in which he stat-
ed that during preemployment examinations he
gave patch tests with phenol formaldehyde resins

in which he "superficially scarified the skin and
many of the new workers were found to be hy-
persensitive, showing a reaction immediately or
within twenty-four hours.” It is evident that the
patch test performance is not yet clearly under-
stood. The skin should not be traumatized before
or during the application of the test substances.
Oil from uncooked cashew nuts, for example, is
a primary irritant. Such irritants should never be
used in patch testing sensitized persons, as they
will react intensely to the slightest amount. Patch
testing with essential oils, such as cashew nut
shell oiP and oil of cinnamon, may precipitate a
generalized reaction which will leave the patient
so sensitized that he may succumb to the weak-
est solutions.

Preemployment patch tests are not feasible,
even when a hazard inherent in the industry
concerned is involved, for the method is not
dependable. Negative reactions may impart a
false sense of security with resultant disaster.
Application of chemicals under occlusive dress-
ings for twenty-four to seventy-two hours does
not parallel an ordinary industrial exposure.
False positive reactions cause unnecessary re-
jection of applicants or needless expenditures
to eliminate hazards which in reality do not
exist. False negative reactions are deceiving.
It is impossible to test adequately for air-
borne poisons, physical agents and their in-
fluence, trauma, powders and oils which inter-
fere with bodily functions, or vital agencies,
or to reproduce the ever-changing chemical
combinations of an industrial process or the
prolonged contact day after day with weak
solutions or steam.

Dermatologists have all obtained negative re-
sults with an alleged irritant, and then observed
a prompt outbreak when the patient returned to
work. With such clinical evidence, negative re-
actions to patch tests should be disregarded. I
do not believe that preemployment patch tests on
workers are practical but I do believe that new
chemicals in industry should have preemploy-
ment tests, made either upon subjects who will
not later work with these chemicals or on guinea
pigs.

Legal Aspects

In states where compensation laws enumerate
the various occupational diseases covered there

268

Jour. ALS.M.S.

DERMATITIS AND ECZEMA— DOWNING

may be little question about a disturbance or dis-
I ease of the skin, but in jurisdictions like Massa-
j chusetts where occupational diseases as such are
i not compensable and a personal injury- must be
[ proved, the doctor must know what the words
mean. The Supreme Judicial Court of Massa-
chusetts (in Panagotopulos’ Case, 276 Mass.

' 600) said that it can be “found that industrial
I dermatitis, though termed a disease, is trace-
I able to a 'personal injury’ within the meaning of
the workmen’s compensation law ( S. 26) , and is
I not a 'simple disease resulting from employment.”

, Furthermore, the “personal injury” for which
I compensation is payable is “physical deterioration
! flowing immediately from corporeal collision with
; a foreign substance set in motion by the business
j of the employer performed by the employe by vir-
tue of his contract of service.” (Sullivan’s Case,
265 Mass. 497.)

Following these decisions the Massachusetts
industrial accident board allows compensation for
dermatitis caused by industrial irritations and
for non-industrial dermatoses aggravated to the
disabling stage by contact with irritants on the
: job. The board-members have no list of compen-

! sable and non-compensable skin conditions but
I treat each particular case on its own merits. In
one instance a board member accepted a physi-
I cian’s opinion that a generalized cutaneous dis-
I ease was due to industrial irritation although ex-
; perts considered it to be a non-industrial psoriasis.

I ]\Iedical testimony that a dermatitis was caused
I by contact with some chemical at work has been
held sufficient to justify an award, even though
the injurious chemical was not established nor
could the evidence determine whether contact
was by touching the skin or by inhaling vapors.
(Robinson’s Case, 1938 Mass. Adv. Sh. 417.)

' Partial disability as well as total disability com-
pensation is available under most compensation
acts. Thus a workman who has acquired a h}"per-
sensitivity which prevents his working at a par-
ticular job, but not to employment in general, is
protected. (McCann’s Case, 286 Mass. 541.)

Recently the ^Massachusetts legislature adopted
an amendment to permit the industrial accident
board to refer a claim of industrial disease to
three impartial physicians. These are allowed to
examine the claimant, study the pertinent medi-
cal records, and investigate working conditions.
Their opinion as to the extent and cause of dis-
ability is binding upon the parties and cannot be

rebutted. The constitutionality of this statute is
being debated extensively, but until invalidated by
the Supreme Judicial Court it is the law. This
provision obviously prevents both employe and
insurer from having a trial on the claim of in-
dustrial disease. However, workmen’s compen-
sation insurance coverage in Massachusetts is
voluntary for both employe and employer. If
either does not want insurance he can take his
chances at common law. On such reasoning the
statute would seem to be constitutional.®

Patch tests are assuming unexpected and un-
warranted legal importance. A physician cannot
testify to results unless he himself performed the
tests. Courts have recently questioned whether it
was good medical practice to fail to do patch
tests, and injunctions are being issued on the as-
sumption that the test substance used was not the
one which caused the trouble but merely looked
like it. I recently had an opinion ruled out by
the Commissioner at the industrial accident board
because I could not remember whether the in-
surer or the patient had brought the patch test
materials to my office one year before. Tests with
stock solutions cannot be admitted as evidence.

Treatment

Mffien a worker suffers from an occupational
dermatitis the sooner he is removed from his
work the speedier will be his recovery. If his
eruption is severe locally, with intense edema and
vesiculation, or extensive in its distribution, hos-
pitalization is advisable, particularly where both
hands are affected. Warm wet dressings are of
value. The alteration of two per cent boric acid
solution with a solution of potassium permanga-
nate, 1-5000, constantly for twenty-four to foiiy-
eight hours has been found effective. If there is
considerable pruritus, aluminum acetate, 5 grams
in 100 c.c. of water, will often give prompt relief.
Mhth the subsidence of the edema and a resulting
oozing and desquamation of the skin, lotions and
pastes will be next in order. If there is any sug-
gestion of infection, 5 to 10 per cent of sulpho-
ichthyolate of ammonia (ichthyol) may be added.
Soap and water should be avoided. The skin
should be cleansed with mineral or olive oil and
should be sponged with either a 2 per cent hot
boric acid solution or the following solution which
should be used in the quantity of a tablespoon to
a quart of hot water : potassium chlorate 30, so-
dium borate 30, sodium bicarbonate 60. Persist-

April, 1941

269

DERMATITIS AND ECZEMA— DOWNING

ent pruritic patches may be treated later with
ointments containing oil of cade or crude coal tar
or monacetate of pyrogallic acid (leningallol).
However, the prolonged use of ointments seems
to irritate these dermatitides, especially where
they have become secondarily infected by bacte-
ria. Treatment with dyes may then be beneficial.
Gentian violet and brilliant green may be used in
varying strengths and combinations such as ;
brilliant green 1.2, gentian violet 1.2, alcohol 60,
and water 60. Various industries have vainly
sought specific remedies for prompt relief of their
employes’ cutaneous eruptions. It must be re-
membered, however, that once the skin is in-
jured, the first principle of treatment is rest,
sufficient for normal processes to heal the affected
part. The physician must use only soothing rem-
edies. Idiosyncrasies to drugs such as mercury,
resorcin, and picric acid, should be anticipated
and guarded against by pretherapeutic patch
testing. The average period of healing is about
six weeks. Ultraviolet radiation is of value if it
is not used too soon ; the same holds true of x-ray
therapy. Cooperation of the patient is essential
and the physician soon discovers if he is dealing
with a malingerer.

Prevention

Klauder and his associates,’^^ in an excellent
article, found that in many cases, trade dermatitis
is really not caused by the substances encountered
at work, but rather with their removal by meth-
ods harmful to the skin. The importance of me-
chanical devices in the prevention of industrial
dermatitis and the need of education of workmen
and • others concerned are emphasized in these
studies, which include discussions of the use and
abuse of soap, and soap substitutes, proper and
improper employment of emollients, unneces-
sary exposure of the skin to primary irritants and
to sensitizing substances, use of a brush instead
of a cloth, use of a tool instead of the hand, use
of protective sleeves, and provision of simple
and easily provided facilities and preventive
measures.

They discuss the value of protective hand
creams and suggest several formulae, the most
practical one in my opinion being : white wax 10,
hydrous wool fat 6, sulphonated olive oil 10, pet-
rolati 75. They advise the application of olive
'oil, neat’s-foot oil, or linseed oil before work for
men whose hands become soiled. This facilitates

the removal of dirt, grease, and grime, especially!
if the oil is applied again to the soiled parts and . -
removed with a clean cloth before washing with!
soap and water. As a substitute for the mechanic"
abrasive soaps, equal parts of sulphonated neat’s- j >
foot oil and liquid petrolatum containing 25 perJ, ^
cent gelatin are added to white granulated cornl
meal in the proportion of 1^ parts by weight of
the corn meal and 1 part by weight of the oil
mixture. At the end of the day’s work equal
parts of hydrous wool fat and olive oil, cotton-
seed oil or neat’s-foot oil should be rubbed on
the skin. A formula containing sulfonated neat’s- *
foot oil 45, light liquid petrolatum 45, gelatin 25 ■
per cent aqueous solution 10, is recommended as '
a satisfactory detergent and exerts more of an
emollient action. Oatmeal flour, especially when
combined with boric acid solution instead of wa-
ter, is suggested for cleansing the hands of pa-
tients with eczema.

Prevention can be achieved by education;
hence, public lectures to the laity and talks
to employers and workers are important. The
latter in particular should be told about irritat-
ing contacts, such as poisonous chemicals and
plants. Labeling is also essential in the case
of all volatile solvents and irritating chemicals.
Even though a laborer suffers a mild derma-
titis he may, under careful observation, con-
tinue his work and later become desensitized.
This happened in my own experience to va-
rious bakelite molders, treers, and even mica
workers, who under treatment were enabled
to pursue their chosen trades.

References

1. Coca, Arthur F. : Classification of allergic diseases of the

skin: Diagnosis and treatment. Deliberationes Congressus

Dermatologorum Internationalis IX. -i. Budapestini, 13-21,
(September) 1935.

2. Downing, J. G. : Are patch tests of real value in derma-
tology? New Eng. Jour. Med., 219:698-703, (Nov. 3) 1938.

3. Downing, J. G. ; Cutaneous eruptions among industrial

workers, a review of two thousand claims for compensa-
tion. _Arch. Dermat. and Syph., 39:12-32, (January) 1939.

4. Downing, J. G. : Dermatitis from cashew nut shell oil.

Jour. Indus. Hyg.. 22:, (May) 1940.

5. Downing, J. G. : Industrial dermatoses and their treatment.
New Eng. Jour. Med.. 206:666-680, (March 31) 1932.

6. Downing, J. G. : Industrial dermatoses: Treatment and

legal aspects: Review of recent literature. Jour. Indus.

Hyg., 17:, (July) 1935.

7. Downing, J. G. ; The skin and the compensation law in
the United States (Treer’s dermatitis). In: Deliberationes
Congressus Dermatologorum Internationalis, 2:210-216. Leip- '
zig: Johann Ambrosius Barth, 1936.

8. Foerster, Harry R.: The compensation laws and related
medicolegal considerations. Jour. A.M.A., 111:1542-1547,
(Oct. 22) 1938.

9. Guertin, F. L. : The author wishes to express his thanks

to Mr. Guertin for his kind assistance.

10. Horner, S. G. : Dermatitis from oranges and lemons. Lan-
cet, 2:961, 1931.

11. Klauder, Joseph V.. Gross, Elmer R., and Brown, Her-
man. Prevention of industrial dermatitis; with reference
to protective hand creams, soap and the harmful role of

Tour. M.S.M.S.

270

FORENSIC PSYCHIATRY— FATTERSON

some cleansing agents. Arch. Dermat. and Syph., 41 ;
331-357, (February) 1940.

12. Lane, C. Guy: Occupational skin disease — a preventable

disease and a challenge to modern preventive medicine.
New Eng. Jour. Med., 215:859-865, (Nov. 5) 1936.

13. Osborne, Earl D., and Jordon, James W. : The practical

aspect of the prevention of industrial dermatoses. Jour.
A.M.A., 111:1533-1536, (Oct. 22) 1938.

14. Senear, F. E. : Dermatitis due to woods. Jour. A.M.A.,

101:1527-1532, (Nov. 11) 1933.

15. Shelmire, Bedford: Contact dermatitis from vegetation;

patch testing and treatment with plant oleoresins. Jour.
Southern Med. Assn., 33:No. 4, 337-346, (April) 1940.

16. Sulzberger, M. B., and Wise, F. ; The contact or patch test
in dermatology; its uses, advantages, and limitations. Arch.
Dermat. and Syph., 23:519-531, 1931.

Forensic Psychiatry
In Michigan*

By Ralph M. Patterson, M.D.
Ann Arbor, Michigan

Ralph M. Patterson, M.D.

M.D., University of Michigan, 1930. M.S.
in Neuropsychiatry, University of Michigan,
1938. _ Diplomate of the American Board of
Psychiatry and Neurology, 1939. Assistant
Professor of Psychiatry at the N europsychiatric
Institute. Member of the Michigan State Med-
ical Society.

■ Prior to the termination of the eighteenth
century the psychiatrist played little or no role
in the criminal court as the court would
entertain no defense on the grounds of insanity
other than "absolute madness.” However, the
concept became gradually less narrow during
the first half of the nineteenth century, when
such terms as partial insanity and delusional in-
sanity came into vogue. A truly scientific pre-
sentation of the findings of the psychiatrist con-
tinued to be hampered by the philosophical con-
siderations of the “knowledge of right or wrong”
and the strictly punitive approach. Progress was
further restricted by the opinions of the judges
formulated after the famous McNaghton trial of
1843. The tendency to pursue a very literal in-
terpretation of these opinions has persisted to
date. From a legal viewpoint an individual is
either perfectly sane, or absolutely insane. The
inflexibility of this concept has made expert testi-
mony difficult, particularly in borderline cases.
In order to convince the jury of a defendant’s
sanity or insanity, attorneys have indulged in
a form of questioning which has done much to
degrade the statements of the psychiatrist in
court. Throughout such procedures there has
been a tendency to focus the attention of the

*Based on a paper presented to the Michigan Society of
Neurology and Psychiatry, March 14, 1940.

April, 1941

court on some isolated symptom or feature of
the personality, thus avoiding a presentation of a
complete study of the individual as a whole.
Very able lawyers and psychiatrists have made
numerous attempts to change the punitive pro-
cedure and philosophy so that emphasis might be
placed on the individual rather than the crime.
Despite such efforts there has been no appreciable
change in attitude until very recently.

As a reaction to public interest and feeling,
the Michigan State Legislature has made various
attempts during the past several years to obtain
more adequate control over criminal sexual
psychopaths. As a result of these efforts the
Public Acts of 1939 contain two laws that de-
serve the attention of the medical profession and
are of particular concern to psychiatrists. Act
No. 165 is for the purpose of defining and con-
trolling criminal sexual psychopaths and Act No.
259 provides for psychiatric examination of in-
dividuals charged with murder. With the ad-
vent of these new laws psychiatric testimony
assumes increased importance and in order to
meet this responsibility adequately it would be
decidedly advantageous if a certain uniformity of
attitude and approach could be cultivated.

In order to control criminals with a propensity
for the commission of sexual offenses the State
of Michigan found it necessary to forsake the
punitive approach and to consider such individ-
uals as psychopathic personalities. Although the
law concerning sexual psychopaths was pro-
moted primarily to permit the control of such
individuals, it does secondarily permit the culti-
vation of a much more scientific approach to
crime. Under the procedure which it provides
the psychiatrist can present a complete case
study, including the defendant’s social back-
ground, personality development, the psychody-
namics of his behavior, including if he wishes,
recommendations and prognosis. Since such
case studies can be presented in writing and
since it is unnecessary in most instances for the
psychiatrist to appear in court, the confusing
and misleading questioning previously indulged
in is thus largely eliminated. It is to be expected
that if the psychiatrist presents complete, prac-
tical, and conservative case studies his reputation
in court will be appreciably improved and the
advantages of individualized criminology will
become at once obvious. If the courts can be
convinced of the practicability of study and treat-

271

merit rather than punitive procedures it will be-
come less difficult to fulfill the recommendations
of the American Bar Association. These recom-
mendations include in brief : Psychiatric service
in every criminal and juvenile court, a psychiat-
ric study before sentence is passed by the judge,
a similar service in every penal and correctional
institution, and a similar report before transfer
or release of any prisoner.

Such progress having been accomplished, the
second step would be the development of a
tribunal composed of psychiatrist, psychologist
and social investigator working as a team in co-
operation with all courts and correctional institu-
tions.

The third step would be the most radical
and would envisage the abandonment of the
present punitive philosophy entirely. Under
the proposed regime the jury would become
purely fact-finding in character and defendants
instead of being sentenced would be commit-
ted to a treatment commission. This commis-
sion, composed of educator, sociologist, psy-
chiatrist and criminologist, would after a
period of study and investigation designate
the type of treatment to be followed, such as
education, trade training, psychotherapy, et
cetera.

Probation would similarly be under the super-
vision of this group. Those individuals who
were not found to be amenable to treatment or
probation would remain under protective deten-
tion for an indefinite period. It is readily seen
that such a program would not burden the state
hospitals with psychopaths but would, on the
contrary, place more psychiatrists and other
scientifically minded individuals in the field of
criminology. The initiation of such a program
would be at first costly but would become in the
course of years more economical than the present
punitive approach and would, furthermore, con-
stitute a sound scientific and social advancement.

INCREASED WISDOM

A man should never be ashamed to admit that he
has been wrong. It is another way of saying that he is
wiser today than he was yesterday. — The Journal of
the Michigan State Dental Society, April, 1940.

272

Cbrnnic Non-Tuberculous
Lesions of tbe Lungs*

By J. E. Lofstrom, M.D.,
and

F. C. Jewell, M.D.

Detroit, Michigan

J. E. Lofstrom, M.D.

M.D., University of Minnesota, 1931. As-
sistant Professor of Radiology, Wayne Univer-
sity College of Medicine. Radiologist, Detroit
Receiving Hospital, Alexander Blain Hospital,

St. Mary’s Hospital. Member, American Col-
lege of Radiology, Radiological ^ Society of
North America, Michigan Association of Roent-
genologists, Detroit Roentgen Ray and Radium
Society, Michigan State Medical Society.

F. C. Jewfxl, M.D.

B.S., Michigan State College, 1933. M.D.,

Wayne University College of Medicine, 1937.

Resident Radiologist, Detroit Receiving Hospi-
tal.

“ There are certain portions of the body
which, by virtue of their anatomic structure,
are more amenable to diagnosis by the roentgen-
ogram than by many other methods. With this
advantage of diagnosis at hand, we owe it to our-
selves as well as the patient to recognize and com-
prehend any deviation from the normal chest
film. Such a field in medicine is chronic non-
tuberculous lesions of the lungs, and it is the pur-
pose of this paper to enumerate and differentiate
by means of the roentgenogram those chronic
lesions that are the greatest diagnostic problems.

We must never lose sight of the value of a cor-
rect history from the patient, for the roentgeno-
gram of the chest without history as to occupa-
tion, duration, and clinical symptoms is nil. The
importance must be exceptionally stressed in the
differentiation of pneumoconiosis from pneu-
momycosis or simple passive congestion of a de-
compensated heart.

For convenience in presentation, the following
grouping will be followed.

1. Normal chest variations

2. Passive congestion

3. Chronic pneumonitis

4. Chronic bronchitis

5. Bronchiectasis

(a) Saccular

(b) Cylindrical

6. Lymphoblastoma

7. Pneumoconiosis

(a) Without pneumonitis

(b) With pneumonitis

*From the ITepartment of Roentgenology, Alexander Blain
Hospital, and Receiving Hospital.

Jour. M.S.M.S.

LESIONS OF THE LUNGS— LOFSTROM AND JEWELL

8. Abscess

9. Cystic disease of the lung and pneumocele

10. Pneumomycosis

(a) Blastomycosis

(b) Aspergillus

(c) Actinomycosis

11. Infiltrative carcinoma

12. Bronchogenic carcinoma

(a) With atelectasis

(b) With abscess

Types of Chests

Normal lungs may be found in a various num-
ber of deformed chests. The rachitic chest is one
typically characterized by the rachitic rosary,
Harrison’s groove, and a prominent sternum.
The long, flat chest is the type commonly met
with in pulmonary tuberculosis. The thorax is
elongated ; the elliptical shape of the ribs is flat-
tened, and the subcostal angle is acute. The bar-
rel chest form tends to become cylindrical with
a greater cubic capacity. The ribs are elevated
and everted; the Louis’ angle becomes promi-
nent.^®

Passive Congestion

Passive congestion is to be found almost in-
variably in some cardiac affection. Probably the
most common form is that known as hypostasis.
The roentgenogram usually shows the increased
vascular markings due to stasis of the pulmonary
veins, with an accompanying enlargement of the
heart. Passive congestion is usually confined to
the bases with a variable amount of fluid in the
costophrenic angles.

Chronic Pneumonitis

Chronic pneumonitis is variously described as
chronic pneumonia, interstitial pneumonia, and
cirrhosis of the lung. The etiology of the lesion
embraces nearly every type of disease to which
the lung is subjected. Properly speaking, it is
the result of the potential chronicity of the pri-
mary infection. In any chronic pneumonitis of
long standing duration, a varying degree of fibro-
sis with of course all its features develops.
Chronic passive congestion sometimes leads to
interstitial changes. In the chest film one vis-
ualizes a diffuse infiltration of one or both lung
fields with numerous areas of density of varying
sizes interspersed. There is also an accentuation
of the linear markings which represents fibrosis.
The tendency of an unresolved broncho or lobar

pneumonia is to pass into a stage of chronic
pneumonitis.

Chronic Bronchitis

Chronic bronchitis is never a disease of the
young, but contrary to the consensus of opinion
it is encountered in the advancing years of those
patients with faulty circulation or some chronic
pulmonary condition such as asthma or emphy-
sema. Chronic bronchitis is not to be confused
with other lesions, for it is here that fibrosis
about the bronchi and peripheral emphysema pro-
duce thickening of both hilum shadows, marked
increase in the linear bronchovascular markings
at the base, and a diffuse increased radiability of
the lungs.

Bronchiectasis

The diagnosis of bronchiectasis, especially the
early stages, has been much improved in the past
few years by the use of iodized oil and improved
x-ray technic. Here again the diagnosis is not
usually confused with other lesions. The radi-
ologist suspects bronchiectasis from a plain chest
film by the honeycombed appearance of the inner
bases of the lungs. It is from this that a broncho-
gram is advised to rule out simple pneumonitis.
With a bronchogram we can recognize two types,
the cylindrical and the sacculated form. The first
presents a uniformly dilated bronchus which may
be likened to a glove. A subvariety of the cylin-
drical form is the fusiform type, in which the
dilated bronchi taper somewhat at the terminal
extremity. The sacculated type shows the ex-
treme degree of dilatation; bronchi dilating at
one particular point or at varied points of the
same branch.

Lymphoblastoma

Lymphoblastoma is a rare form of tumor of
the lung, and reports are usually limited to a few
cases. Blastoma produces an enlargement of the
lymph nodes of the mediastinum and hila with a
generalized infiltrative process extending periph-
erally (Fig. 1). This may produce a very con-
fusing picture, especially if there is no enlarge-
ment of the hilar nodes, and one must rely upon
the process of elimination of other diseases by
the greatest cooperation with the clinician. En-
larged glandular elements elsewhere in the body
should throw immediate suspicion on to the blas-

April, 1941

273

LESIONS OF THE LUNGS— LOFSTROM AND JEWELL

Fig. 1. Hodgkin’s disease. Enlargement Fig. 2. Third stage pneumoconiosis Fig. 3. Pneumocele following pneu-
of lymph nodes of hila with generalized with nonspecific pneumonitis of the right monia outlined by means of a broncho-
infiltrative process extending peripherally, lower lobe. gram.

toma group. Because of the sensitivity of Hodg-
kins’ disease to deep x-ray therapy, it is urgent
that a diagnosis be made.

Pneumoconiosis

Pneumoconiosis is a term applied to pulmonary
affections which develop as the result of the in-
halation of dust. This word has become quite
comrnon due to its relation with compensation
laws. There have been various names offered to
designate the type of dust which is the offender.
Until now we are not able to demonstrate the
etiology from the chest film.’^” X-ray examination
is the only certain method of recognizing the dis-
ease. In the radiograph one might class the dis-
ease according to three stages. In the first stage
there is an increase in the hilum shadows with a
prominence of the linear markings and bronchial
shadows. The second stage is characterized by a
mottled appearance throughout the lung structure
which is most marked in the middle two-thirds
of both lung fields. The third stage is recognized
by the appearance of a diffuse fibrosis. The fine
mottled appearance gradually becomes conglom-
erate and finally passes into a stage of dense
fibrosis. Fibrous bands may be seen branching
into various directions throughout the lung fields.
The heart and mediastinum may be displaced or
retracted from the fibrosis. It is during this
transition from the second to the third stage that
non-specific pneumonitis occurs as a result of the
inability of the lungs to combat infection (Fig.
2). Tuberculosis is frequently superimposed.

Pulmonary Abscess

Pulmonary abscess may be single or multiple.
The single abscess may be the result of pneumo-
nia, foreign bodies, or the inhalation of emboli
from an operative field in the upper respiratory
tract. The diagnosis is not difficult in the radio-
graph when one realizes they most frequently oc-
cur in the lower lobes in contradistinction to the
tuberculous cavity and abscess in a necrotic neo-
plasm. An abscess usually starts with an area of
hazy radiating density in the lower half of the
lung field. Later, a cavity develops in which the
lung markings are not well outlined. In the up-
right position one may see a fluid level. If the
abscess remains for a considerable length of time,
extensive fibroid changes in the adjacent lung tis-
sue may develop. Multiple abscesses are very
seldom chronic and will therefore not be dis-
cussed.

Congenital Cystic Disease

Congenital cystic disease of the lung until 1925
was considered rare. Gradually various writers
reported the number of cases coming under their
observation, and hence the increasing importance
in the differential diagnosis of pulmonary lesions.
In 1934 Wood^^ reported sixteen cases at the
Mayo Clinic and in 1935 Pearson^® reported that
one hundred and seventy-two cases had been re-
corded. In congenital cystic disease the condition
may persist into adult life. In fact, they may re-
main silent as long as they are sterile. In most
cases a number of thin walled cystic cavities are

274

Jour. M.S.M.S.

LESIONS OF THE LUNGS— LOFSTROM AND JEWELL

Fig. 4. Blastomycosis. Patchy-like pnen- Fig. 5. Aspergillosis. Proliferative type Fig. .6. Primary carcinoma of the right
monic areas distributed throughout both of infiltration radiating from the right upper lobe. Infiltrative type,
lung fields. hilum into the periphery.

noted with or without a small amount of fluid in
them. They may be irregularly distributed
throughout both lung flelds. Cysts completely
filled with fluid without evidence of any inflam-
mation surrounding may simulate other pulmon-
ary lesions. Usually a single congenital cyst
filled with fluid resembles a benign tumor such
as a neurofibroma, hydatid cyst, or aneurysm.
In such cases the radiologist may have to be con-
tented with the diagnosis of nonspecific tumor
mass of the lung. Multiple air filled cells are
often mistaken for a hernia of the stomach or
bowel through the diaphragm, and it is safer then
to examine the patient with an opaque media.

Pulmonary Pneumocele

Pulmonary pneumocele, as the name implies, is
a tumor filled with air. Pierce and Dirkse^^ have
described it as a “localized alveolar or lobular
ectasia which are a few contiguous emphysema-
tous alveoli that tend to increase in volume slowly
or rapidly and assume massive proportions.”
Our feeling is that the pneumocele has its origin
in a lobular pneumonia which has weakened
those alveoli that finally dilate. Some writers
feel this is the result of a congenital weakening.
The pneumocele is recognized in the radiograph
by a thin walled, air containing cyst that may or
may not contain fluid. There is usually evidence
of a resolving pneumonic process about the area.
It has been necessary in our department to resort
to opaque media to rule out a loop of bowel in
the pleural cavity (Fig. 3).

Pneumomycosis

Pneumomycosis should be considered in the
differential diagnosis in anyone having clinical
pulmonary symptoms. Because of the rarity of
the disease, it is often overlooked. It is reported
that pneumomycosis was first described "' by
Hughes Bennett in 1842.^^ Later other writers
reported tuberculosis with a fungus infection' of
the pleura. Since then more attention has been
placed on the importance in recognizing mycotic
infections. It is well to state here that; the' diag-
nosis of these lesions is not primarily One of the
radiologist. The roentgenologist can go far to-
wards recognizing it, but not until the ' laboratory
technician has isolated the fungus can one say
definitely it is a mycotic infection.

Blastomycosis.— Whtn blastomycosis attacks
the respiratory tract, both hila and bronchi are
first involved with the appearance of small
bronchopneumonic-like , areas distributed through-
out the lungs (Fig, 4). The disease frequently is
limited to the upper lobes and more often the
right upper lobe. However, it may involve the
entire lung field. The extent of invasions may
vary from several small discrete areas of density
simulating miliary tuberculosis to a large con-
fluent consolidation of the lung. In the more se-
vere chronic cases the confluent areas may break
down, become necrotic, and produce an abscess.

Aspergillosis. — Chronic pulmonary aspergillo-
sis is another fungus infection that should be
considered in every patient having chronic pul-
monary symptoms. The occupational history is

April, 1941

275

LESIONS OF THE LUNGS— LOFSTROM AND JEWELL

of some importance as it has been observed main-
ly in those individuals who come in contact with
grain, flour and chickens. The onset of the dis-
ease is not far removed from that of an acute
upper respiratory infection which continues on
and is similar to chronic pulmonary tuberculosis.
The roentgenogram reveals a proliferative type
of infiltration radiating from each hilum into the
periphery of the lung field (Fig. 5). Some have
described it as a spider web pattern. As the dis-
ease continues, a varying degree of fibrosis may
develop. There is an absence of calcified lymph
glands and involvement of the apex which should
distinguish it from tuberculosis. By no means is
the roentgenogram conclusive, and one must rely
upon the sputum examination and skin tests for
the diagnosis.

Actinomycosis. — Actinomycosis is another fun-
gus infection which is relatively widespread in
cattle and is frequently referred to as “big jaw.”
The disease is transmissible to man through the
alimentary or respiratory tract of cattle and
manifests itself most frequently as a chronic pul-
monary lesion. The roentgen chest examination
reveals a diffuse miliary process involving both
lung fields and the pleura. The infiltrative proc-
ess may coalesce and become a confluent indis-
crete area of opacity. As a result of the poor
blood supply, necrosis and cavity formation may
occur. There may be fluid in the pleural cavity
due to the invasion of fungus ; this being true, it
is an advantage to examine the fluid for sulphur
granules. Spontaneous perforation of a chest
wall abscess is strongly suggestive of underlying
mycotic infection. In any event the conclusive
diagnosis rests upon the finding of streptothrix
actinomyces.

Primary Carcinoma

Within the past two decades our ideas regard-
ing primary carcinoma of the lungs have under-
gone a sharp change. At first it was thought that
the incidence of malignant disease of the pul-
monary system was increasing. Perhaps this is
partially correct with the increase in exhaust
gases, asphalt and tar that are supposed to be a
predisposing factor, but there has been an in-
crease in the ease with which lesions of the chest
may be diagnosed. The radiologist suspects it,
the bronchoscopist obtains a biopsy, and the pa-
thologist confirms it.

For the sake of convenience, in our department

we divide carcinoma of the lung into two groups : i

(1) The infiltrative type which invades the par- j
enchyma and only later obstructs the bronchus; I

(2) The obstructive type which primarily arises j

from the wall of the bronchus and obstructs the |
lumen early, causing a varying degree of atelec- i
tasis of that portion of the lung. |

The infiltrative type (Fig. 6) represents the
undifferentiated cell carcinoma which is charac-
terized by a fan-shaped peribronchial infiltration
extending peripherally from the root of the lung.
There is early metastases and consequently a
mass at the hilum is frequently noted. Secon-
dary infection is a less common complication than
in the obstructive type of growth.

With the obstructive type the problem of dif- j
ferential diagnosis becomes exceedingly great, ;
especially when an inflammatory process such as ’
pneumonia is superimposed. The decreased
aeration from atelectasis promotes a fertile spot '
for pneumococcic growth. An inflammatory ,
process alone can usually be distinguished by the ,
relative absence of atelectasis and the more ir- ■
regular character of the lesion. Delayed resolu- j
tion of a pneumonic process in a patient past >
thirty-five should cause one to be on his guard
for the possibility of underlying malignancy.
Tumors of the mediastinum and aneurysms of
the aorta may cause atelectasis. In such cases
the Potter-Bucky diaphragm is necessary for
greater penetration. Fluoroscopy and blood se-
rology are extra advantages that aid in the dif- j
ferentiation. The opacity produced by tumors of i
the mediastinum does not extend into the lung as j
far as that produced by malignancy of the bron-. j
chi ; also they are more sharply defined, and |
rarely produce obstruction of a bronchus.^® A [
bronchogram may also be done to show the ob- ;
struction or narrowing of a bronchus from a t
neoplasm.

Carcinoma with Abscess. — The relative grade ;
of malignancy often gives rise to another diag- •
nostic feature, namely, bronchogenic carcinoma ,
with abscess. The tumor mass growing rapidly
destroys large numbers of vessels and thus de- j
creases its own blood supply so that the central
mass starts to degenerate. This central mass
finally liquifies and is discharged into a bronchus.
By so doing, air reaches the necrotic mass and
produces the picture of a lung abscess on the ra- i
diograph. Pyogenic abscess may develop distal

276

Jour. M.S.M.S.

INTESTINAL SUCTION DRAINAGE— HARTZELL

to the neoplasm as a result of the secondary in-
fection. The degenerating malignant area of ex-
cavation should not be confused with the smooth,
thick wall cavity of a pyogenic abscess, or the
thinner walled cavity of tuberculosis, or the ex-
tremely thin walled cysts or pneumoceles.^
Metastatic malignancy, extrathoracic irradia-
tion, tularemia, echinococcic cyst and reaction
secondary to aspiration of mineral oil are other
chronic conditions which should always be borne
in mind in an adequate differential diagnosis of
chronic pulmonary lesions.

Summary and Conclusions

1. This paper is presented in the hope that the
physician may become better acquainted with
those non-tuberculous lesions of the lungs that
should be suspected in any patient with chronic
pulmonary symptoms.

2. From our experience it is evident that the
roentgenologic hianifestation of the discussed le-
sions of the lungs is a most valuable diagnostic
aid.

3. In a great percentage of cases the roent-
genologist can recognize the abnormality or the
pathology and in most of the others can
contribute facts which, when coupled with the
history and laboratory data, will lead to a diag-
nosis.

4. We have briefly discussed the salient char-
acteristics in the roentgenogram of the chest
which may aid in the differential diagnosis.

5. Any chronic pulmonary lesion is very seri-
ous and in any event the result either directly or
indirectly produces a remarkable mortality rate.

References

1. Adams, W. E., and Swanson, W. W. : Congenital cystic

disease of lung. Review of the Literature, Internat. Clin.,
4:205-220, (December) 1935.

2. Amberson, J. B., Jr., and Reggins, H. McL. : Lipiodal in
bronchography; its disadvantages, dangers and uses. Am.
Jour. Roentgenol, and Rad. Therapy, 30:727-746, 1933.

3. Anspach, W. E., and Wolman, I. J. : Large pulmonary air

cysts of infancy, with special reference to pathogenesis
and diagnosis. Sur. Gynec., and Obst., 56:635-645, (March)
1933.

4. Brines, O. A., and Kenning, J. C. : Bronchiogenic carci-

noma. Am. Jour. Clin. Path., 7:i20, (March) 1937.

5. Clerf, L. H. : Carcinoma of the bronchus. Radiology,

28:438, (April) 1937.

6. Dubrau, J. L. : Congenital cyst of the lung. Radiology,

24:480-488, (April) 1935.

7. Elofsser, L. : Congenital cystic disease of the lung.

Radiology, 17:912-929, (November) 1931.

8. Farrell, J. F. : Diagnosis of bronchial carcinoma: A clini-

cal and roentgenologic study of fifty cases. Radiology,
26:261, (March), 1936.

9. Freidman, E. : Congenital cysts of the lungs. Am. Jour.

Roentgenol, and Rad. Ther., 35:44-52, (January) 1936.

10. Gardner, L. U. : The pathology and roentgenographic

manifestations of pneumoconiosis. Jour. Am. Med. Assn.,
(February 17) 1940.

11. Graham, E. A.: Primary carcinoma of the lung or

bronchus. Ann. Surg., 103:1, (January) 1936.

April, 1941

12. Graham, E. A.: Bronchiectasis and fibrosis of the lung.

Arch. Dis. Childhood, 4:170-189, (August) 1939.

13. Kirklin, B. R. : Congenital cysts of the lung from the

roentgenological viewpoint. Am. Jour. Roentgenol, and
Rad. Ther., 36:19-29, Quly) 1936.

14. Manges, W. F. : Primary carcinoma of the lung. Am.

Jour. Roentgenol, and Rad. Ther., 27 :858, (June) 1932.

15. Norris, E. M., and Landis, H. R. M. : Diseases of the

Chest. Sth ed. Philadelphia: W. B. Saunders Company,

1933.

16. Pearson, E. F. : Cystic disease of the lungs with report of

eight cases. Illinois Med. Jour., 67:28-37, 1935.

17. Peirce, C. B., and Dirkse, P. E. : Pulmonary pneumatocele

(localized alvealor or lobular ectasia). Am. Jour. Roent-
genol. and Rad. Therapy, 28:651-665, (June) 1937.

18. Ridler, L. G. : Outline of Roentgen Diagnosis. Atlas

Edition. Philadelphia: J. B. Lippincott Co., 1938.

19. Rosedale, ,R. S., and McKay, D. R. : A study of fifty-

seven cases of bronchogenic carcinoma. Am. Jour. Cancer,
26:493, (March) 1936.

20. Shapiro, I. S., and Jaches, L. : Bronchography and bron-

chiectasis. New York State Jour. Med., 35:441-447, 1935.

21. Van Ordstrom, H. S. ; Pulmonary aspergillus. Cleveland
Clinic Quarterly, 7:66-73, 1940.

22. Wood, H. G. : Congenital cystic disease of the lungs:

clinical study. Jour. A.M.A., 103:815-821, 1934.

Intestinal Snction Drainage

In Facilitating One-stage
Resection of the
Right Colon*

By John B. Hartzell, M.D.
Detroit, Michigan

John B. Hartzell, M.D.

M.D., University of Cincinnati College of
Medicine, 1925. Fellow, American College of
Surgeons. Chief of the Department of Sur-
gery, Charles Godwin Jennings Hospital. Asso-
ciate Surgeon, Receiving Hospital, Detroit.
Assistant Professor of Clinical Surgery, Wayne
University. Member of the Michigan State
Medical Society.

■ Once the diagnosis of carcinoma of the large
bowel has been made and the absence of posi-
tive evidence of distant metastases determined, it
becomes the duty of the physician to see that
surgical exploration of the lesion is undertaken
as soon as the patient’s condition will permit.
In general, the main causes for delay are; the
presence of a poor state of general nutrition ;
anemia ; dehydration ; and distention. Regardless
of the location of the tumor, before its eradica-
tion is undertaken, much good can be accom-
plished by a period of preparation to allow de-
compression of the bowel above the lesion and
rehabilitation of the patient.

Rehabilitation is brought about by hydration
and feeding. The patient should be put on a
high protein, high caloric, low residue diet, as
well as an adequate fluid intake. We have come
to feel that if any formidable operative procedure
is contemplated, especially when intestinal

♦From the Department of Surgery, Wayne University and
the Surgical Service of the Charles Godwin Jennings Hospital
and the Receiving Hospital, Detroit, Michigan.

277

INTESTINAL SUCTION DRAINAGE-HARTZELL

anastomosis is to be done, the body should
be supplied with the materials which enable it
to carry on the reparative processes concerned
with healing. In a recent review of the literature

Fig. 1. (left) Carcinoma of ascending colon. The balloon-tip
intestinal tube has been passed until the tip rests in the term-
inal ileum. Bowel between dotted lines is to be removed.

Fig. 2._ (right) Right half of the colon has been resected and
the terminal ileum anastomosed to transverse colon. The tip of
tube with balloon deflated is allowed to remain just proximal
to stoma. Constant suction is maintained.

on the subject of abdominal wound disruption,
Winfield and myself^ found that in a series of
1,458 collected cases of wound disruption 33
per cent occurred following operations for carci-
noma or for peptic ulcer. During the past year,
working with Irvin, ^ in the course of some 200
determinations of the concentrating levels of
plasma vitamin C and serum protein, we were
amazed to find routinely low values in all cases
of malignant disease of the gastro-intestinal tract.
We have therefore made it a routine to restore
the serum protein level to approximately 7 gms.
and the plasma ascorbic acid concentrations above
.7 mgm. per 100 c.c. of blood plasma. If anemia
is present, the red count should be brought to
normal with blood transfusions, and blood plas-
ma transfusions may be used as an adjunct to
feeding in bringing the serum protein levels up
to normal.

Decompression of the Bowel

We have come to believe decompression of
the bowel is fully as important in the preparation
of the patient as rehabilitation. In the presence
of distention from a varying degree of obstruc-
tion, rehabilitation cannot be accomplished until
decompression has been satisfactorily brought
about. Decompression of the bowel, depending
upon the degree of stenosis and the location of

the tumor, is now done in several ways. Occa-
sionally in a low growth, one easily reached with
the proctoscope, it is possible to pass a rectal tube
beyond the stenosed area. Following this proce-
dure, gentle rectal irrigations are given and the
accumulated fecal material above the tumor is
removed. Not infrequently, after the bowel has
been thoroughly emptied, the stenosed area opens
up sufficiently so that the patient may be able to
go to stool normally. If the growth is higher in
the colon, simple irrigations alone will sometimes
accomplish this result. Gentle purging, as sug-
gested by Jones,^ may help in the removal of
solid fecal material above the tumor, but this
should be done carefully and only if the ob-
struction is not complete. When these methods
do not promptly relieve the distention, it may be
necessary to do a cecostomy or a colostomy. As
an adjunct to the handling of the problem of
distention from a partial to complete large bowel
obstruction, we have recently been accomplish-
ing decompression by means of the balloon-tip
intestinal tube, the tip of which passed into the
lower ileum and serves as an efficient enteros-
tomy. During the past three years, on the Surgi-
cal Service of Receiving Hospital, this tube has
been passed in over 150 cases of organic bowel
obstruction. Johnston and his co-workers^ have
proved this to be of decided value in the decom-
pression of distended bowel, and in the treatment
of obstruction.

Miller- Ahhott Tube. — In any obstruction of
the colon we do not hesitate to introduce the
balloon-tip intestinal tube into the intestine. If the
obstruction is situated in the left colon, intuba-
tion may not afford prompt relief and other
means of decompression must be employed. It
must be remembered that prompt relief of the
distention, that is the emptying of the colon, is
essential and a cecostomy or colostomy may be
necessary depending upon the location of the
tumor, completeness of obstruction, and evidence
of reflux into the small intestine. In obstruction
situated in the right half of the colon, intestinal
intubation may prove an efficient means of reliev-
ing distention, and, generally speaking, the closer
the obstruction to the cecum, the more good can
be accomplished by this method.

It is a well recognized fact that, in the pres-
ence of gastric or intestinal distention, operation
upon the gastro-intestinal tract is more hazardous.

278

Jour. M.S.M.S.

INTESTINAL SUCTION DRAINAGE— HARTZELL

not only because of increased danger of spill of
intestinal content, but because of interference
with healing at the suture line. The use of
gastric suction by means of a small nasal catheter

tion of a case in which the right half of the
colon was removed for an obstructing carcinoma
of the ascending colon. It also illustrates the
value of suction drainage at the operative site

Fig. 3. (.left) The colon is shown outlined with a barium
enema. A characteristic stenosed filling defect will be noted
in the center of the transverse colon. The diagnosis — carcinoma
of the ascending colon.

Fig. 4. (right) Flat x-ray plate of the abdomen on first post-
operative day. The skin clips and wire tension .sutures will be
noted in the transverse type incision. There is a mild distension,
consequently the balloon was inflated and passed until the tip
was in the vicinity of the stoma giving relief of the distension.

Fig. 5. (left) X-ray taken on the tenth postoperative day. A
small amount of thin barium mixture was injected down the
tube. This will be seen as a small puddle just proximal to the
stoma.

Fig. 6. (right) X-ray taken the following day after the tube
had been clamped for twenty-four hours reveals that there is no
distension and only a few flakes of barium remain in vicinity
of the stoma. The tube can now be safely removed.

has long been employed in operations upon the
stomach, both before, during and after opera-
tion, If intestinal surgery is contemplated in
the lower reaches of the intestinal tract, we feel
it even more important to take measures which
will eliminate the possibility of distention. Ran-
kin® recognizes this danger, and in performing
a one-stage removal of the right colon, advises
a complementary ileostomy 20 to 30 cm. above
the anastomosis. The blood supply of the small
bowel and the colon is normally not as rich as
that of the stomach, with the result that disten-
tion may have an even more disastrous effect
upon healing of the suture line. When possible,
we pass the balloon-tip intestinal tube before
operation to a point in the intestine just proxi-
mal to the probable site of anastomosis (Fig. 1).
Not infrequently there is some swelling and
edema about the site of the stoma which tends
to occlude it sufficiently to obstruct the passage
of intestinal content. Aspiration just proximal
to the stoma obviates distention (Fig. 2). Leigh
and his associates,® and Ravdin and AbbotF have
recently advised this procedure.

Typical Case

The following case is illustrative of the ad-
vantage of intestinal intubation in the prepara-

in controlling distention postoperatively, and in
facilitating operation.

The patient, a fifty-nine-year-old male, was admitted
to the Surgical Service with a one-year history of
vague abdominal pain, occasional nausea, a gradual
increase in the number of stools, and some weakness
without weight loss. Examination revealed a moderate
abdominal distention and a tumor in the right loin.
A proctoscopic examination was negative. A barium
enema revealed a characteristic filling defect (Fig. 3).
The balloon-tip intestinal tube was passed until the
tip lay in the lower ileum, with relief of the abdominal
distention. The patient was put on a high protein, low
residue diet, and given several blood transfusions.
He was also given 500 mgm. of vitamin C daily,
and one week later operation was performed, and a
large obstructing carcinoma was found in the ascend-
ing colon. The ileum was severed about 5 inches from
the cecum, and the proximal end anastomosed to the
transverse colon. The distal portion, together with
the cecum, ascending colon and hepatic flexure was
removed. The next day there was noted slight dis-
tention. An x-ray revealed the tube to be not quite
far enough down (Fig. 4). Accordingly, the balloon
was distended with air and the tube passed until the
tip was in the vicinity of the stoma, giving complete
relief of the distention. On the tenth postoperative day
a small amount of barium was injected down the
tube. This will be seen as a small puddle just
proximal to the stoma (Fig. 5). The tube was then
clamped for twenty-four hours. The following day

April, 1941

279

PNEUMOCOCCUS MENINGITIS— MYERS, ROBB AND CLAPPER

the barium passed in the istool. X-ray revealed only
a few flakes remaining near the stoma, and the absence
of any distention (Fig. 6). Consequently the intestinal
tube was removed. The use of intestinal suction drain-
age in this case not only permitted operation in one
stage, but contributed markedly to the smooth con-
valescence of the patient. Two months following the
operation, no evidence of obstruction at the site of
the stoma was evident, barium introduced by enema
passing readily into the ileum. The patient has re-
mained well and is having regular and well formed
bowel movements.

This case is presented to illustrate the advan-
tages of intestinal intubation -with suction drain-
age in the management of lesions of the right
colon. Its use has permitted us to perform a
one-stage procedure where we formerly used
two stages, and with less difficulty to the patient
than is usually attended with either part of the
staged procedure.

Bibliography

1. Hartzell, J. B., and Winfield, J. M. : Disruption of abdom-

inal wounds; collective review. Internat. Abstr. Surg., 68;
585-601, 1939; Surg. Gyn. and Obst., (June) 1939.

2. Hartzell, J. B., Winfield, J. M., and Irvin, J. L. : Plasma
vitamin C and serum protein levels in wound disruption.
Jour. A.M.A. (In press.)

3. Jones, T. E. : One-stage abdomino-perineal operation for

carcinoma of the rectum. Ann. Surg., 102:64-68, (July)
1935.

4. Johnston, C. G., Penberthy, G. C., Noer, R. J.,_ and Ken-
ning, J. C. : Decompression of the small intestine in the
treatment of intestinal obstruction. Jour. A.M.A., 111:1365-
1367, (October) 1938.

5. Leigh, O. C., Jr., Nelson, J. A., and Swenson, P. C. The
Miller- Abbott tube as an adjunct to surgery of small in-
testinal obstructions. Ann. Surg., 111:186-212, (February)
1940.

6. Rankin, F. W. : Common errors in diagnosis and treatment
of cancer of the colon and rectum. South. Med. Jour.,
30:386-392, (April) 1937.

7. Ravdin, I. S., and Abbott, W. O. : The use of the Miller-
Abbott tube in facilitating one-stage resections of the small
and large bowel. New Internat. Clinics, 1:178-185, (March)
1940, New Series 3.

THE WAY OF THE WORLD

In the world of yesterday women were denied sex
freedom but permitted to have many children. In the
world of today women are permitted larger sex
freedom but are denied children. In both cases a
phase of living is denied and adjustment to the
situations created is demanded through the instrumen-
tality of a palliative. In the former case the gift of
children palliated the loss of freedom ; in the latter
case the loss of children is palliated by a means of
allegedly safe promiscuity and of economic adjustment
to an inequitable social order.

War should perhaps be regarded in somewhat the
same light. It is a complete denial of rational living
for which a number of fraudulent palliatives are
offered, such as the absorption of the unemployed
into the army and into wartime industrialism, and the
temporary granting of favors to the underprivileged,
none of which gestures touch upon the basic inequities
which inure in a sick society. — Medical Times, April,
1940.

Type III PneumoGoccus
Meningitis

Recovery Following
Sulfathiazole*

By Gordon B. Myers, M.D., J. Milton Robb, M.D.,
and Muir Clapper, M.D.

Detroit, Michigan

Gordon B. Myers, M.D.

M.D., University of Michigan, 1927. Profes-
sor of Medicine, Wayne University College
of Medicine. Director of Medicine, Detroit
Receiving Hospital.

J. Milton Robb, M.D.

^ _ M.D., Wayne University College of Medi-

cine, 1908. Fellow, American College of
Surgeons. Fellow, Royal College of Surgeons
(Edinburgh). Associate Professor of Surgery,

Wayne University College of Medicine. Head
of Otolaryngology, Receiving Hospital, Detroit.

Muir Clapper, M.D.

M.D., Wayne University College of Medi-
cine, 1937. Instructor in Medicine, Wayne
University College of Medicine. Junior As-
sociate in Medicine, Receiving Hospital, De-
troit.

" Comparative studies in animals have shown

that sulfathiazole is much less toxic than sulfa-
pyridine, yet is almost as effective against the
pneumococcus, and probably superior against the
staphylococcus.^’2>3>4,5,8,io Preliminary reports in
humans^’^ are in keeping with the results in ani-
mals but much more clinical experience will be
necessary to conclusively determine which is the
preferable therapeutic agent. The following
case is reported to record; (1) a dramatic re-
sponse of a type III pneumococcus meningitis
to sulfathiazole; (2) the development of bron-
chopneumonia during the administration of large
doses of the drug; (3) the sudden appearance of
renal insufficiency and sulfathiazole retention ;
(4) stupor, delirium and generalized epilepti-
form convulsions as possible toxic manifestations.

Case Report

F, W., forty-six years old, white, female, diabetic,
was admitted to Detroit Receiving Hospital, January
11, 1940, complaining of draining ears since December
26, and right-sided convulsions of five days’ duration.

Past history. — A diagnosis of diabetes mellitus was
made in 1934, when the patient consulted a physician
because of pruritis vulvae, polydipsia, polyphagia and
polyuria. At that time she had an infected toe which
failed to heal until she was placed on a diabetic diet

*From the Department of Medicine of Wayne University and
City of Detroit Receiving Hospital.

280

Jour. M.S.M.S.

PNEUMOCOCCUS MENINGITIS— MYERS, ROBB AND CLAPPER

with 10 units of regular insulin before breakfast and
supper. Three years ago she discontinued insulin
and ceased to follow her diabetic diet. Since then she
had had intermittent pruritis vulvae but was otherwise
in fair health.

Present illness began on December 23, 1939, with
running nose, sore throat, dry cough and bilateral
earache. On December 26, both ear drums ruptured
spontaneously and a purulent discharge appeared. Dur-
ing the succeeding week she had an irregular fever,
with chilly sensations and sweats, and was confined
to bed. The bilateral aural discharge continued and
hearing diminished greatly. On January 4 she noticed
weakness and ataxia in the right hand, which soon
extended to the right arm and leg. On January 6
she had a clonic convulsion which began in the right
hip, spread to the right leg, then to the right arm
and lasted about a minute. During the next five days
there were five to ten similar attacks daily. About
fifteen seconds before the onset of each attack, she
had a sense of epigastric discomfort which she recog-
nized as a warning of an impending convulsion. Dur-
ing the attacks she was unable to speak but did not
lose consciousness. She was not incontinent and did
not bite her tongue during the convulsions.

Physical examitration on admission revealed an apa-
thetic white female with rather marked bilateral
middle ear deafness. There was a purulent discharge
in both external auditory canals and bilateral mastoid
tenderness, rnost marked on the right. The left pupil
was slightly larger than the right and both reacted well
to light and accommodation. The optic fundi were
normal except for a single cotton-wool patch in the
left fundus and slight arterial narrowing. There was
lateral and slight vertical nystagmus. The lateral nys-
tagmus was of first degree with quick component to
the left. The neck was not stiff and the Brudzinski
and Kernig signs were negative. There was distinct
muscular weakness with hypotonia in the right arm
and leg. Biceps, triceps, patellar and ankle jerks were
diminished on the right. Plantar reflexes were normal.
There was definite ataxia on the right in both the
finger-to-nose test and the heel-to-knee test with eyes
open as well as with eyes closed. There was asynergy
and dysmetria on other movements of the right arm
and leg. Adiadokocinesis was present in the right arm
and check movements were impaired. Sensory exami-
nation was entirely negative. The remainder of the
physical examination was negative except for a blood
pressure of 180/110. X-rays showed cloudiness of
the right mastoid and petrous portion of the temporal
bone and slight cloudiness of the left mastoid. Roent-
genogram of the chest was negative.

Pre-O'perative course (January 11-16). — The tempera-
ture was normal in the morning and averaged 99.6”
F. in the evening. The pulse ranged between 90 and
110. The blood sugar on admission was .286 per cent
and the urine contained a large amount of glucose.
There was no significant acidosis, however, since the
blood COg combining power was 49 volumes per cent

and the urine contained only traces of acetone. The
patient was placed upon a four-feeding diet furnishing
a total of 206 grams of available glucose and received
30 units of protamine zinc insulin and 10 units of
regular insulin daily. The glycosuria was reduced to
a trace but the fasting blood sugar ranged between
.170 per cent and .250 per cent. The patient was
observed in several unilateral clonic convulsions simi-
lar in every respect to those described in the present
illness. The convulsions were considered by all ob-
servers to be typical of the Jacksonian epilepsy charac-
teristically associated with supratentorial lesions, and
quite unlike the torsion movements sometimes accom-
panying cerebellar lesions. The remainder of the
neurological examination, however, pointed to a right
cerebellar rather than a cortical lesion. The hypotonia,
ataxia, et cetera, increased in degree, but no new
neurological signs appeared. Spinal puncture, on Jan-
uary 12, revealed a clear /fluid under a pressure of
125 mm. water with normal Queckenstedt response.
The fluid contained only 2 WBC per cu. mm. and
the globulin, colloidal gold and Kline tests were nega-
tive.

Operation. — A right complete mastoidectomy was de-
cided upon because of persistent purulent discharge
from the middle ear together with signs of advancing
cerebellar disease and was performed on January 17
by one of us (J.M.R.). The mastoid was filled with
granulation tissue and .contained a moderate amount
of pus. After exenteration of the mastoid, the sig-
moid sinus was uncovered and found to be normal.
The dura of the posterior fossa was exposed in the
area of Trautmann’s triangle. On elevating the dural
plate, a small perforation of the dura was found
which led into a cyst 2x5 cm., which displaced the
cerebellum to the left. The cyst was aspirated and a
serous exudate was removed. The cerebellar convolu-
tions could easily be seen and were distinctly flattened.
The cyst cavity was lightly packed with iodoform
gauze and the mastoid was closed in the usual
manner. Further exploration of the cranial cavity was
not attempted.

Development of type III pneumococcic meningitis.
— On January 18, the temperature rose to 104°. There
was profuse thin purulent discharge from the mastoid
incision, but no clinical signs of meningitis. On the
morning of January 19, however, she was irrational,
the neck rigid and Kernig’s sign was positive. A
spinal puncture was done, revealing a cloudy fluid
containing 12,100 polys per cu. mm. No organisms
were found on direct smear. Since staphylococcus
aureus had been recovered from the aural discharge,
sulfamethylthiazole* was started on the supposition
that the meningitis was also staphylococcic. Spinal
fluid culture, however, showed that the meningitis was
due to type III pneumococcus. In the 18-hour interval
before the report of the culture, the patient received a
total of 10.5 G sulfamethylthiazole without any dem-

*The sulfamethylthiazole was furnished by the Winthrop Chem-
ical Company; the sulfathiazole was furnished by E. R. Squibb
and Sons.

April. 1941

281

PNEUMOCOCCUS MENINGITIS— MYERS, ROBB AND CLAPPER

onstrable effect on the course of the meningitis. Spinal
fluid, taken two and one-half hours after the last dose,
contained 16,500 polys per cu. mm. and was still posi-
tive for type III pneumococcus. Sulfathiazole’*' was
then substituted.

Dramatic response of the meningitis to sulfathiazole.
— A total of 14 G of sulfathiazole was given on Janu-
ary 20, the first 5 G intravenously as the sodium
salt, the remainder by mouth. The following morning
she was mentally clear and her temperature was nor-
mal. The spinal fluid cell count had fallen to 472
per cu. mm. and organisms were no longer recovered.
Sulfathiazole was continued in a dose of 2 G every
four hours (six times daily) up until the morning of
January 30. The meningeal signs cleared up, the
spinal fluid remained sterile and the cell count dropped
to 33 on January 26, and to 5 per cu. mm. on February
2.

Development of hr oncho pneumonia during the course
of sulfathiazole therapy. — On January 24, the patient
had a chill, followed by a rise in temperature to
104.6®. Blood culture at this time showed a non-
hemolytic staphylococcus aureus. Inasmuch as four
previous and isix subsequent blood cultures were
sterile, it seems likely that this organism was merely
a contaminant. On January 25, there were physical
and roentgen signs of a patchy consolidation in the
left lower lobe. Previous x-rays of the chest, taken
on January 12 and 19, were negative. The consolida-
tion thus developed during sulfathiazole therapy. The
blood level of free sulfathiazole on the morning the
consolidation was detected was 6.7 mg. per cent. The
sputa were consistently negative for pneumococcus,
both on direct smear and on passage through the
mouse. For this reason, and because the development
of pneumonia during the administration of massive
doses of sulfathiazole was most unexpected, other pos-
sible explanations for the consolidation were sought.
The unilateral distribution of the lesions excluded left
heart failure and made multiple pulmonary emboli most
unlikely. There was no previous history nor subse-
quent evidence to suggest bronchiectasis. There was
no evidence of massive collapse but the possibility
that the consolidation began as a lobular atelectasis
could neither be definitely established nor excluded.
The course was compatible with pneumonia. There
was moderate pleuritic pain but the sputum did not
become rusty. The temperature ranged between 100°
and 102° until January 29, when it fell to normal.
Roentgenogram on February 3, showed only slight de-
crease in the consolidation but a check ray, on Febru-
ary 16, showed complete resolution.

Development of renal insufficiency with retention of
sulfathiazole. — The patient received 10.5 G isulfamethyl-
thiazole on January 19, 14 G sulfathiazole on January
20 and 12 G of sulfathiazole daily thereafter up until
January 30, for a total of 127 G. Blood concentra-
tions of free sulfathiazole were quite variable during

*The sulfathiazole was furnished by E. R. Sqtiibb and Sons.

the first week of therapy, ranging from 1.2 to 8.1
mg. per cent, the highest level being obtained on
January 27. No determination was made on January
28. Between January 19 and 28, the patient frequently
complained of nausea, and vomited on seven occasions.
Nausea and vomiting were present before the drug
was started and may have been due, in part, to the
meningitis. There were no other toxic symptoms until
January 29, when the patient became drowsy and dis-
oriented. The blood concentration of free sulfathiazole
had increased abruptly to 20 mg. per cent. The next
morning, the blood’ level was 17.4 mg. per cent and
the drug was discontinued. On January 31, twenty-
four hours after sulfathiazole had been stopped, the
blood level was 15.1 mg. per cent. Sulfathiazole ex-
cretion was very slow. The blood level was 12.1 mg.
per cent on February 1 ; 5 mg. per cent on February 3 ;
and was still 1.1 mg. per cent on February 7, eight
days after the drug had been discontinued. There was
coincident nitrogen retention, the blood urea being 96
mg. per cent on February 2 and again on February
5, then falling gradually to 60 mg. per cent on Febru-
ary 8 and to 38 mg. per cent on February 23. On that
date, 24 days after sulfathiazole had been discontinued,
renal function was still impaired as shown by a urea
clearance of 46 per cent. The urea clearance rose to
87 per cent on March 13, but the ability to concentrate
the urine was impaired. During the period of sulfa-
thiazole administration and up until February 3, speci-
fic gravities as high as 1.025 had been attained in sugar
free specimens. Thereafter, a specific gravity above
1.015 was not attained either in numerous single speci-
mens or on repeated concentration tests (Olmstead
method) until just before discharge when it reached
1.017. Urine specimens were examined for blood daily
during the administration of sulfathiazole and during
the two-week period following its withdrawal. No
more than 1 red blood cell per high power field was
found at any time. In spite of the absence of hematuria
and the failure to find acetylsulfathiazole calculi in the
urine, the renal insufficiency was considered a toxic
manifestation of sulfathiazole. Paralleling the nitrogen
retention, there was a fall in blood CO^ combining
power. The latter, in volumes per cent was as follows :
52 on January 30, 36 the following day, 27 on February
1, 20 on February 3, 30 on February 5 and 58 on
February 10. Since the diabetes was well controlled
during the entire period on a daily carbohydrate intake
of 150 grams, the fall in blood COg combining power
was attributed to the renal insufficiency.

Toxic manifestations referable to the central ner-
vous system. — On January 29, coincident with an
abrupt rise in blood sulfathiazole to 20 mg. per cent,
the patient became drowsy and disoriented. The next
morning she was delirious, the blood level being 17.4
mg. per cent. At noon on January 30, she had a gen-
eralized epileptiform convulsion which lasted about
two minutes. She had four similar convulsions during
the afternoon and evening and two the next forenoon,
at which time the blood level was 15.1 mg. per cent.
These were the first and only convulsions since the

Jour. M.S.M.S.

282

PNEUMOCOCCUS MENINGITIS— MYERS, ROBB AND CLAPPER

mastoidectomy. These convulsions differed from those
vEich had occurred pre-operatively in that they were
bilateral and symmetrical from the onset and were
accompanied by loss of consciousness and followed by
stupor. The question arose as to whether the con-
vulsions and other cerebral symptoms were due to the
sulfathiazole, to hypoglycemia, to extension of the
intracranial inflammatory process or to cerebral vascu-
lar complications of the hypertension and nephritis.
Acute nicotinic acid deficiency was not considered at
that time but, in retrospect, it can probably be excluded
inasmuch as a complete recovery was made without
the administration of nicotinic acid or any of its deriva-
tives. The convulsions were probably not due to hypo-
glycemia because one occurred while an intravenous
injection of glucose was in progress (after 250 c.c.
had run in) ; another occurred shortly after an intra-
venous injection of 25 G of glucose. The blood sugar
taken after another convulsion was 71 mg. per cent.
The fasting blood sugars had been normal since
January 26. No regular insulin had been given since
January 24, and the protamine insulin, which had been
temporarily increased during the meningitis to bring
the diabetes under control was reduced to 30 units
on January 30. Neurological examination still showed
slight hypotonia and hyporeflexia on the right but failed
to reveal any evidence of extension of the intra-
cranial lesion. The meningeal signs had entirely
disappeared and the spinal fluid, on February 2, was
under a pressure of 100 mm. and was entirely nega-
tive. There was no significant change in blood pres-
sure, no evidence of edema of the optic discs nor
retina on the days when she had the convulsions.
There were no further convulsions after January 31,
whereas the renal insufficiency persisted for many days.
Thus, by a process of exclusion of other possibilities as
well as from the fact that the stupor, delirium and
convulsions appeared coincidentally with the abrupt rise
of blood sulfathiazole and gradually disappeared as
the blood level fell, it was concluded that the cerebral
symptoms were probably due principally to sulfathiazole
retention. Convulsions have been reported in animals
from the intravenous injection of sodium sulfapyridine,®
but not, to our knowledge, from sulfathiazole. It is
possible that the coexisting intracranial infection was
a conditioning factor.

Other toxic manifestatiam. — The hemoglobin was 10
G per 100 c.c. at the advent of chemotherapy and
was at the same level on January 30, when sulfathiazole
was discontinued. During the next few days the
hemoglobin fell off rapidly, reaching a low point of
6 G per 100 c.c. on February 6. There was no gross
hemorrhage to account for the anemia, and no evidence
of hemoglobinuria nor jaundice. Ferrous sulfate was
started on February 10, and the hemoglobin had re-
turned to its original level by March 4.

Condition at discharge on March 26. — The diabetes
was well controlled by 35 units of protamine zinc insu-
lin at 7 :00 A. M. daily. The mastoid wound granu-
lated in very slowly and was nearly healed by the

end of March. The left otitis media and mastoiditis
cleared up during the course of sulfathiazole therapy
without operative intervention. Hearing was practically
normal. The ataxia, dysmetria, asynergy, etc., disap-
peared, the only residual neurological signs being ny-
stagmus on lateral gaze and slight hypotonia and
hyporeflexia on the right. The Jacksonian convulsions,
which had occurred at the rate of 5 to 10 daily before
the operation, did not return after surgical drainage
of the cyst, which was found pressing against the cere-
bellum. While this would suggest that the Jacksonian
convulsions were due to this cyst, the possibility of an
unrecognized cortical inflammatory process which
cleared up spontaneously or as a result of sulfathiazole
could not be excluded.

Summary

A case of type III pneumococcus meningitis
is reported which recovered following sulfathia-
zole. A total of 127 grams was given over a
period of ten days. Bronchopneumonia devel-
oped during sulfathiazole therapy. The course
was also complicated by the sudden appearance
of renal insufficiency with sulfathiazole retention,
stupor, delirium and epileptiform convulsions.

Bibliography

1. Barlow, O. W., and Homburger, E. ; Specific chemotlierapy
of experimental staphylococcus infections with thiazole deriv-
atives of sulfanilamide. Proc. Soc. Exptl. Biol. Med., 42:792,
(December) 1939.

2. Barlow, O. W., and Homburger, E.: Thiazole derivatives
of sulfanilamide and experimental beta-hemolytic streptococ-
cal and pneumococcal infections in mice. Proc. Soc. Exptl.
Biol. Med., 43:317, (February) 1940.

3. Long, Perrin H., and Bliss, Eleanor A.: Bacteriostatic

effects of sulfathiazole upon various microorganisms. Its
therapeutic effects in experimental pneumococcal infections.
Proc. Soc. Exptl. Biol. Med., 43:324, (February) 1940.

4. Long, Perrin H., Haviland, James W., and Edwards, Lydia

B. : Acute toxicity, absorption and excretion of sulfathiazole
and certain of its derivatives. Proc. Soc. Exptl. Biol. Med.,
43:328, (February) 1940.

5. McKee, C. M., Rake, (Jeoffrey, Creep, R. O., and Van Dyke,
H. B. : Therapeutic effect of sulfathiazole and sulfapyridine.
Proc. Soc. Ibcptl. Biol. Med., 42:417, (November) 1939.

6. Marshall, E. K., Jr., Bratton, A. C., and Litchfield, J. T.,
Jr.: The toxicity and absorption of 2-sulfanilamidopyridine
and its soluble sodium salt. Science, 88:597, (December 23)
1938.

7. Pool, T. L., and Cook, E. N. : Sulfathiazole and sulfame-

thylthiazole in the treatment of infections of the urinary
tract. Proc. Staff Meetings Mayo Clinic, 15:113, (February
21) 1940.

8. Rake, Ceoffrey, Van Dyke, H. B., Corwin, W. C., McKee,

C. M., and (Sreep, R. O. : Pathological changes following

prolonged administration of sulfathiazole and sulfapyridine.
Jour. Bact., 39:45, (January) 1940.

9. Reinhold, J. C., Flippin, H. F., and Schwartz, L. : Observa-
tions of the pharmacology and toxicology of sulfathiazole
in man. Am. Jour. Med. Sci., 199 :393, (March) 1940.

10. Van Dyke, H. B., Creep, R. O., Rake, Ceoffrey, and Mc-
kee, C. M. : Observations on the toxicology of sulfathiazole
and sulfapyridine. Proc. Soc. Exptl. Biol. Med., 42:410,
(November) 1939.

A bill has been introduced in the Maine Senate,
reports the A.M.A. Journal which “proposes to create
a state board of eugenics which is to be authorized to
order the sexual sterilization of any person living in
the state who is feeble-minded, insane, syphilitic, a
habitual criminal, a moral degenerate or a sexual
pervert and is thereby a menace to society in that he
or she may produce offspring having an inherited
tendency to the social inadequacies noted.”

April, 1941

283

i

RADIATION THERAPY— SICHLER

Radiation Therapy

In the Treatment of Malignant
Disease of the Genito-
urinary Tract

By H. G. Sichler, M.D.

Lansing, Michigan

Harper G. Sichler, M.D.

M.D., University of Michigan, 1928. Mem-
her, Radiological Society of North America,

American College of Radiology. Diplomate;

American Board of Radiology. Member of the
Staffs^ of St. Lawrence and E. W. Sparrow
Hospitals. Member of the Michigan State
Medical Society.

■ In general, malignant growths of the genito-
urinary tract were formerly considered to be
among the less favorable class of tumors in
their response to high voltage x-ray therapy.
This attitude was based upon the generally dis-
appointing and unsatisfactory results obtained
in trying to prevent recurrence and metastasis
of the tumor by postoperative radiation after
the growth has been removed as far as possible
by operative interference.

In the last few years, since the first report of
Waters, Lewis and Frontz^° (Johns Hopkins), in
1934, on the pre-operative radiation treatment
of kidney tumors, it has been found that most
malignant tumors of the kidney, bladder and
testicle are definitely radiosensitive, and the em-
phasis has shifted towards pre-operative radia-
tion for the purpose of reducing the size of the
tumors and devitalizing them, so that subsequent
operation becomes easier, more complete, and
productive of better results.

To understand how radiation by high volt-
age x-rays can have this effect, it is necessary
to recall that the sensitivity to radiation of
any tissue depends on the degree of immatu-
rity and lack of differentiation of the cells of
which it is composed. Very cellular, rapidly
growing tumors are more susceptible to radia-
tion than are adult type cells, and this is espe-
cially true of embryonal tumors such as Wilms
tumors in children, embryonal carcinoma of
the ovary and testis and a few others.

There are many variations, however, because
even tumors of definitely embryonal origin con-
tain cells of different grades of differentiation,
often containing a quite high proportion of adult

cells. The effect of radiation is to produce
necrosis of the most radiosensitive cells, while
the less sensitive cells are damaged or devital-
ized in proportion to their sensitivity, resulting
in varying degrees of fibrosis or hyalinization
which temporarily inhibit the further growth of
the injured tissues. As a result of the absorp-
tion of the necrosed cells, the total volume of
the tumor decreases, in rough proportion to the
number of the most radiosensitive cellular ele-
ments.

Kidney

From the study of fifteen cases of kidney
tumor in 1935, Waters^ drew the following con-
clusions :

1. Tumors of the hypernephroma type and
embryonal carcinomas are radiosensitive.

2. Papillary carcinomas of the renal pelvis
and the malignant cyst adenomas are radiore-
sistant.

3. Irradiation has caused a striking reduction
in the size of radiosensitive renal tumors and
has rendered tumors which were inoperable, on
account of their large size, operable.

4. Irradiation has caused extensive morpho-
logical changes in sensitive tumors, characterized
by alterations in the cellular structure, extensive
fibrosis, and necrosis. The cells become shrunken.
The cytoplasm may contract around the nucleus,
and in certain cases, the tumor has been com-
pletely destroyed and replaced by fibrous tissue.

5. Normal renal tissue is not damaged by
radiation in proper dosage.

6. Reduction in size begins almost immedi-
ately after the institution of radiation, and con-
tinues for a period of several weeks after ces-
sation of treatment.

7. Operative removal is imperative, and should
be carried out within a few weeks after the first
series, depending on the degree of shrinkage as
revealed by palpation and pyelograms.

8. A regrowth of the tumor will occur if
operation is delayed too long.

9. The pyelogram will diflferentiate the pelvic
and cortical tumors in 80-lCX) per cent of the
cases, and 93 per cent of all cortical renal tumors
have been radiosensitive.

10. If it is found to be impossible to remove
all the growth, postoperative high voltage x-ray
therapy should be used. The results of inserting

284

Jour. M.S.M.S.

RADIATION THERAPY— SICHLER

radium needles into a vascular pedicle which is
involved by a malignant growth have proven
unsatisfactory.

Renal tumors in children, which are nearly
always of the Wilms embryonal type, are ex-
tremely radiosensitive, and show a very rapid
reduction in size during and after radiation ther-
apy. The usual early and rapid metastasis of
these tumors usually makes complete relief dif-
ficult, even though the metastases themselves are
radiosensitive. There have recently been several
newspaper reports of cases of this type. Com-
petent observers^ state that about 25 per cent
of kidney tumors are inoperable because of size
or adhesions when first seen and that pre-opera-
tive radiation will reduce the size of the kidney
in all cases except those of pelvic carcinomas,
which do not comprise more than 10 per cent
of kidney tumors.

Urinary Bladder

Most bladder tumors are of one of two gen-
eral types, according to Ewing papillomata, of
which 50 per cent become maligant, and carcino-
mata diffuse or adenoid.

In the case of the papillomas, whether def-
initely malignant or not, an exception is made
to the general rule and postoperative radiation
following fulguration is generaly advised. This
is to prevent the recurrences which usually oc-
cur.

In the case of frank diffuse infiltrating car-
cinoma, about 50 per cent will be found to be
moderately radiosensitive, so heavy pre-opera-
tive radiation is advised in all cases to reduce
the size of the tumor and devitalize it wherever
possible so that complete operative removal is
made either possible or easier. The radiosensi-
tive group of bladder carcinomas does not seem
to belong to any definite pathological class, and
there is no way known at present to differen-
tiate them in advance from the radioresistant
group.

As an example of the results obtained, one
observer® reports twenty-six cases of advanced
infiltrating carcinoma of the bladder treated with
800 Kv. x-rays ; seven cases (27 per cent) ob-
tained complete or nearly complete regression
so that excision or fulguration could be easily
done; nine cases (35 per cent) obtained partial
regression with relief of symptoms and im-
proved operative conditions; and ten cases (38

per cent) obtained little benefit. Thus approxi-
mately 60 per cent were improved so that opera-
tion became either possible or more complete,
and 40 per cent were unimproved. Heavy doses
are necessary for good results, but severe skin
reactions are not necessary. Similar results can
be obtained with standard 200 Kv. therapy.

Testicle

Tumors of the testicle, like those of the blad-
der, are divided into two main groups (with
many subdivisions). About 50 per cent are
primarily embryonal teratomas or seminomas,
and these are radiosensitive, but they usually
contain also a mixture of more mature and less
sensitive cellular elements. The other half com-
prises a confused group of predominately adult
teratomas or mixed tumors, which are slow grow-
ing and radioresistant. There is no means of
differentiating them clinically from embryonal
teratomas except by the greater rate of growth
and increased output of Prolan A by the em-
bryonal teratomas.

These testicular tumors spread through the
deep lymphatics to the lymph nodes around the
abdominal aorta just below the renal pedicle and
behind the peritoneum, thence through the tho-
racic duct to the subclavian vein and pulmonary
circulation. For this reason radiation therapy,
to be effective, must include the entire abdomen
and mediastinum as well as the primary growth.
The results of treatment of these tumors by
surgery alone by means of orchidectomy, either
simple or radical, have long been disappointing.
The quoted results vary from 10 per cent five-
year cures given by Ferguson,® to 58 per cent
five-year cures reported by Cabot and Berkson,^
and in addition there is about 20 per cent mor-
tality with radical orchidectomy.

In 1934 Ferguson,® at Memorial Hospital in
New York, reported much improved results from
pre-operative high voltage x-ray therapy followed
by simple orchidectomy in cases of teratoma tes-
tis, and introduced the method of checking the
effectiveness of the radiation by means of com-
parative assays of the urinary content of Pro-
lan A. The amount of Prolan A excreted in the
urine was shown to diminish progressively un-
der radiation treatment, and to increase again
with the recurrence of metastases. In his latest
report in 1938, Ferguson gives 40 per cent five-

April, 1941

285

RADIATION THERAPY— SICHLER

year cures for teratoma testis, and urges exten-
sive pre-operative radiation, follov^ed by orchi-
dectomy six to twelve weeks later. Waters® re-
ports 50 per cent five-year cures, and Cabot
and Berkson’- raised their five-year percentage
to 71 per cent with the use of pre-operative and
postoperative radiation.

Prostate

Carcinoma of the prostate is nearly always a
slowly growing and highly radioresistant tumor,
so that the results of radiation therapy, whether
given by external high voltage x-ray or by ra-
dium implantations, are usually unsatisfactory.
The use of radiation does not appear to destroy
or appreciably slow the spread of metastases. In
many cases, however, radiation is of great bene-
fit in relieving the severe pain which often results
from local extension or spinal metastases, and
it is for this purpose that it can be most justi-
fiably used.

The results obtained from the use of radiation
in cases of carcinoma of the prostate are well
illustrated by a recent report^ from the Univer-
sity of Minnesota: of 112 cases treated by radia-
tion alone, 7 per cent were well after twenty-
one months (1^ years). Of sixty-seven cases
treated by resection and radiation, 10.5 per cent
were well after twenty-nine months (2/4 years).
They believe that radiation is desirable regard-
less of the absolute poor end-results, because of
the relief of pain from extension and metastases
and the decreased tendency to recurrent obstruc-
tion after its surgical relief. Not all observers
will agree with this conclusion, and it seems clear
that radiation therapy has not proved to be of
sufficient value to be used routinely in all cases
of carcinoma of the prostate unless the urologist
is convinced that its palliative value is sufficiently
great.

Comment

The fact that x-radiation cannot entirely de-
stroy these growths and so effect a cure by itself
(except perhaps in the most sensitive tumors,
such as Wilms, in which some feel that radiation
alone is sufficient without surgery) does not
mean at all that it is valueless, but only that it
should be used to take the utmost advantage
of the devitalization and shrinkage in size which
is the usual effect of radiation on these tumors.
This obviously means radiation followed by

operation at the time of the maximum radiation
effect — usually three to six weeks. In other
words, we advocate the use of radiation therapy
to induce what may be called a quiescent stage
in the tumor itself, during which operative re-
moval can be performed with greater mechanical
ease and less risk of metastasis.

Conclusions

1. Radiation therapy with high voltage x-ray
should be used as an essential pre-operative pro-
cedure in most cases of genito-urinary malig-
nancy, and its proper use will greatly increase
the successful operative results in malignant dis-
eases of the kidney, bladder, and testicle.

2. About 90 per cent of kidney tumors, in-
cluding all forms except pelvic carcinomas, are
radiosensitive, and should have the benefit of
pre-operative radiation, reserving postoperative
treatment for those containing embryonal tissue
or those whose removal was incomplete.

3. Most papillomas of the bladder, and 60
per cent of bladder carcinomas, are radiosensitive.
Papillomas should have postoperative radiation
to prevent recurrence, and carcinomas should
have pre-operative radiation to improve the op-
erative results.

4. Testicular tumors, especially teratoma tes-
tis, should be treated with pre-operative x-ray
therapy followed by simple orchidectomy, and the
progress of the treatment should be checked by
frequent determinations of the excretory out-
put of Prolan A.

5. Carcinoma of the prostate is generally ra-
dioresistant, and radiation therapy is best re-
served for palliative relief of pain when neces-
sar}^

Bibliography

1. Cabot, Hugh, and Berkson J. : Neoplasms of tesUs: study of
results of orchidectomy with and without irradiation. New
England Med. Jour., 220:192-195, (Feb. 2) 1939.

2. Creevy, C. A.: Results of treatment in cancer of prostate:
Review of 275 cases. Surgery, 5:405-409, (March) 1939.

3. Dresser, R., and Rude, J. C.: Supervoltage roentgen treat-

ment of carcinoma of the bladder. Jour. A.M.A., 111:1834-
1837, (Nov. 12) 1938.

4. Ewing, J. : Neoplastic Diseases. Philadelphia: W. B. Saun-
ders Co., 1922, page 650.

5. Ferguson, R. S.: Studies in diagnosis and treatment of tera-
toma testis. Amer. Jour. Roentgen., 31:356-365, (March)
1934.

6. Ferguson, R. S. : Results of treatment of genito-urinary

tumors by roentgen rays. Jour. Urol., 37:823-831, (June)
1937.

7. Prather, G. C., and Friedman, H. E. : Immediate effect of
pre-operative radiation in cortical tumors of the kidney.
New England Med. Jour., 215:655-663, (Oct. 8) 1936.

8. Waters, C. A.: Clinical Roentgen Therapy. Vol. II, p. 453,
Philadelphia: Lea and Febiger.

9. Waters, C. A.: Clinical Roentgen Therapy, Pohle and as-
sociates. Vol. II, p.. 423. Philadelphia: Lea and Febiger.

10. Waters, C. A., Lewis, L. G., and Frontz, W. A.: Radiation
therapy of renal cortical neoplasms, with special reference
to pre-operative irradiation. Southern Med. Jour., 27: 290-
299, (April) 1934.

286

Jour. M.S.M.S.

GANGRENOUS CHOLECYSTITIS— ASHLEY AND NAROTZKY

Acute Gangrenous Cholecystitis
In Children

Report of a Case in a
Child Aged Four*

By L. Byron Ashley, M.D., F.A.C.S., and
A. S. Narotzky, M.D.

L. Byron Ashley, M.D.

M.D. Wayne University College of Medi-
cine, 1914. Associate Surgeon at Harper Hos-
pital, Detroit. Member of the Michigan State
Medical Society.

A. S. Narotzky, M.D.

M.D., Univer.nty of Michigan Medical
School, 1936. Resident Surgeon at Harper
Hospital, Detroit. Associate member of the
Wayne County Medical Society.

■ In 1734, Mr. Joseph Gibson, Surgeon in Leith

and Member of the Surgeon Apothecaries of
Edinburgh, reported the first case of gall-bladder
disease in a child. His patient was twelve years
old and evidently had a ruptured gall bladder
with liver abscesses. Since then cases have
been reported at intervals but never in sufficient
numbers to consider this condition as common.
In a report in 1928, 226 cases were collected
from the literature and four of that author’s
personal cases were added. By 1938, slightly
over 300 cases had been reported. These were
under 15 years of age and most were of a
chronic nature. Cases, as a rule, are reported
by surgeons as accidental findings at time of
operation.

This should remind us that gall-bladder disease,
even though it be in children, should be included
in a differential diagnosis of abdominal lesions.
Although clinical and post mortem records tend
to show that this condition is quite rare, it is
probable that gall-bladder disease in children is
being overlooked. Acute cases must be included
in the diagnosis, and ruled out completely, before
being cast aside as too rare to occur.

,A recent case on the Surgical Service of Drs.
Brooks and Ashley in Harper Hospital is re-
ported in detail.

Case Report

R. M., a four-year-old male, born May 20, 1936, was
admitted to Harper Hospital at 11 :22 P. M. on June
25, 1939. The history was elicited that he awoke on
June 22, 1939, complaining of abdominal pain. He
drank some milk but refused other food. He vomited

*From the Surgical Service of Harper Hospital, Detroit,
Michigan.

April, 1941

twice that day; the vomitus consisting of ingested
food. The pain was more severe that night. On
the next day (June 23, 1939) the patient felt better
and complained very little. The following day (June
24, 1939) he again complained of severe abdominal
pain and was given laxatives. He vomited twice in-
cluding most of the medicine. He was nauseated and
refused fluids. On June 25, the pain was more severe
and an enema was given without any relief of symp-
toms. The patient was then admitted to the hospital
late that night.

The patient’s birth and developmental history were
normal during the first year. Following this period
the family was disappointed in his inability to gain
regularly and were concerned about his poor appetite.
He had not had any important illnesses except for
a “mild cold” at the onset of his disease.

Examination revealed a fairly well-developed, fairly
well-nourished male child of four years in acute dis-
tress. The throat was • slightly injected. The tongue
was moist. There were small glands in both cervical
chains. There was a suggestion of icterus to the
sclerse. The heart and lungs were negative. Pressure
over the entire abdomen caused the patient pain. Pres-
sure over the right side of the abdomen semed to cause
more pain than pressure over the left side. No masses
were made out. The extremities were negative. A
complete and satisfactory examination of the abdo-
men was not possible because of the irritability of the
patient.

The temperature was 100.4, pulse 144, respirations 20.
There were 7,400 leukocytes with 62 per cent poly-
morphonuclear cells. Urinalysis was negative.

A diagnosis of acute surgical abdomen was made
and the finding of an acute appendix was expected.
Operation was begun at 12:15 A. M., on June 26,
1939, under nitrous oxide-oxygen-ether anesthesia. The
operative dictation reads :

Operation. — A 1J4 inch right pararectus incision was
made through a thin but fairly well developed abdomi-
nal wall retracting the muscle medially. On opening
the peritoneal cavity there was a sudden gush of odor-
less dark brownish-yellow fluid which appeared to be
bile stained. After exploration was carried out for
a few minutes and the cecum could not be located the
incision was enlarged to 3j4 inches. The cecum, ter-
minal ileum, and appendix were normal. There were
no mesenteric glands. There was no evidence of a
Meckel’s diverticulum. On the omentum in the region
of the liver was a 5 centimeter exudative area. In
contact with this was a large, tense, gangrenous gall
bladder. The liver appeared normal with sharp edges.
The gall bladder was aspirated, cultured and a piece
removed for microscopic diagnosis. No stones were
found. Cholecystostomy was done, using two purse
string sutures ; the first including the wall of the tube.
One soft drain was placed in Morison’s pouch. The
abdomen was closed in layers using cat-gut and rein-
forced with two waxed silk retention sutures.

The operation took thirty minutes and at the com-
pletion of the procedure the child was awake and in

287

GANGRENOUS CHOLECYSTITIS— ASHLEY AND NAROTZKY

fair condition. His temperature went to 102° a few
hours later and in twenty-four hours it was 100°
with a pulse of 110. Bile began draining at once and
the child had an uneventful postoperative course.
On the eighth postoperative day the soft drain was
removed. On the thirteenth postoperative day the
cholecystostomy tube came out. The retention sutures
were then removed and the child discharged the fol-
lowing day.

Pathologic Examination. — The culture of the gall
bladder failed to produce a growth. The pathologic
report by Dr. P. F. Morse, pathologist at Harper
Hospital, is presented with a photomicograph.

Gross : A 1 centimeter piece of gall-bladder wall.

Microscopic : The cellular structure of the mucosa

is destroyed and replaced by necrotic tissue shreds.
The gall-bladder wall is edematous and intensely in-
filtrated with round cells. The .structure of the gall-
bladder wall can still be made out in the course of
the connective tissue fibers and blood vessels, but is
torn apart by exudate and islands of necrosis.

Diagnosis ; Acute Gangrenous Cholecystitis.

At the present writing, about one year later, the
child is quite well except that his parents still feel he
is not gaining weight as rapidly as he should. He
has not seen his physician for .some time.

Occurrence. — In 3,000 operations performed
on the biliary tract by the surgical services in
Harper Hospital for twelve years ending in 1940,
the rarity of gall-bladder disease in children is
startling. One case operated at three months was
a cholecystostomy as an emergency procedure for
bile drainage in suspected congenital duct atresia.
It terminated fatally. Post mortem examination
was not obtained. One case of a four-year-old

is here reported. There were two cases in chil-
dren of nine years. One case was a child thirteen
years old and one case fourteen years old.

In the large group of cholecystographic studies
made in Harper Hospital the rarity of a study
in a child leads one to conclude that most phy-
sicians believe this is an impossibe procedure.
Children do tolerate the dye well. Parenteral
administration can be resorted to if necessary.
Improved technique and equipment add to the
feasibility of doing studies in children.

As a rule during appendectomy in a child
when a fairly innocent looking appendix is
found, the surgeon explores the abdomen for
mesenteric glands, Meckel’s diverticulum, and
congenital bands about the terminal ileum. A
diseased gall bladder is easily overlooked be-
cause the incision is inadequate to admit two
fingers for exploration and rather than enlarge
the incision the operator dismisses gall-bladder
disease as a rare entity. If this is the case,
the symptoms which brought the patient to
the physician originally would persist.

Conclusion

1. Gall-bladder disease in children is a definite
entity and probably not very rare.

2. Many cases of gall-bladder disease go un-
discovered because a clinical diagnosis is not
made.

3. Cholecystographic studies should be made
more frequently in children.

4. Surgical exploration of the biliary tract is
not done often enough during the removal of
a so-called “interval appendix.”

5. A case of non-calculus gangrenous chol-
ecystitis in a four-year-old child is reported.

References

1. Beals: Cholecystitis and cholelithiasis in children. South-
ern Med. Jour., 21 :666, 1928.

2. Hadley: Acute cholecystitis after scarlet fever. Indiana

Med. Jour., 7 :10, 1908.

3. Hamerton : Acute cholecystitis at the age of three. British
Med. Jour., 1 :778, 1925.

4. Hamilton, Rich and Bisgord : Cholecystitis and cholelith-
iasis of childhood. Jour. A.M.A., 103 :829, 1934.

5. Holbrook: Non-typhoid cholecystitis in children. Am. Jour.
Dis. of Children, 47 :836, 1934.

6. Miller : Acute cholecystitis in a child four years old.
Zentralblatt f. Chir., 53:3092, 1926.

7. Montgomery : Disease of the gall bladder in children. Am.
Jour. Dis. of Children, 44 :372, 1932.

8. Sobel: Cholecystitis and cholelithiasis in childhood. Arch.

Bed., 55:669, 1938.

9. Velo: Cholecystitis due to a calculus in the cystic duct in
a fourteen-year-old girl. Gazz. d. osp., 48:154, 1927.

10. Zeligs : Acute typhoid cholecystitis in children. Arch. Fed.,
43:485, 1926.

288

Jour. M.S.M.S.

AMEBIASIS— SHERMAN AND WEINBERGER

Amebiasis with Pleura-
Pulmonary Complications

Report of Two Coses*

By George A. Sherman, M.D., F.A.C.P., and
Herbert Weinberger, M.D.

Pontiac, Michigan

George A. Sherman, M.D.

M.D., McGill University, 1924. Fellow,

American College of Physicians. Diplotnate,

American Board of Internal Medicine. Medi-
cal Director, Oakland County Tuberculosis
Sanatorium. _ Member of the Michigan State
Medical Society.

Herbert Weinberger, M.D.

M.D., University of Louisville, 1937. Res-
ident physician. Oakland County Tuberculosis
Sanatorium. Member of the Michigan State
Medical Society.

" The eelative infrequency of pleuro-pulmo-
nar}' complications in amebiasis and the failure
to diagnose such cases during life warrants the
report of these cases.

Case Reports

Case 1. — A white man, aged thirtj'-five, was ad-
mitted July 2, 1938, complaining of blood spitting, pain
in the right chest, cough and abundant sputum. On
February 1, 1938, he had a severe pain in the right
lower chest, pleuritic in type, accompanied b}' chills
and fever. During the next six weeks he was bedfast.
X-ray studies of the chest made in March were nega-
tive. General impairment of health continued. On
May 1, three months after the initial sjTnptoms, he
had a small pulmonary hemorrhage. During the next
two months he continued to spit 100 to 200 c.c. of
hemorrhagic bitter tasting sputum. The pain in the
right chest was frequently referred to the right shoul-
der. When admitted he was weak, dyspneic on exertion,
hemorrhages were profuse and there was complete
loss of appetite. Diarrhea did not occur at any time.

The positive physical findings were marked diminu-
tion of resonance, breath sounds, whispered voice, and
tactile fremitus in the lower half of the right lung.
There was moderate muscle spasm and tenderness in
the right upper quadrant of the abdomen.

The admission laboratory studies showed a mild
leukocytosis. Sedimentation rate (W^estergren) 103 mm.
Blood Kahn negative. Four direct smears and a cul-
ture of the sputum were negative for B. tuberculosis.
Stereo films of the chest showed a dense homogeneous
shadow^ obscuring the lower quarter of the right lung.
Bucky and lateral films localized the density in the
posterior half of the lung field. The right diaphragm
v'us elevated four centimeters higher than the left.

The initial studies failed to establish a definite diag-
nosis. No acid-fast organisms were demonstrated in

*From the Oakland County Tuberculosis Sanatorium.

April, 1941

the studies of the sputum. A diagnostic right pneumo-
thorax was induced. There was no empyema. Addi-
tional films suggested an extensive lung abscess. Lipi-
odol occupied only the anterior half of the middle
lobe. The posterior half was free of oil. Three
bronchoscopic examinations w'ere made. There was no
evidence of neoplasm or foreign body. Our consulting
pathologist suggested we might be dealing with a
liver abscess. A diagnostic pneumoperitoneum was in-
duced. Roentgenograms showed the right lobe of the
liver to be firmly adherent to the diaphragm. The
stools were then examined and amebae were demon-
strated on two occasions. Emetine and stovarsol therapy
was begun at once.

During the period between admission and the date
when the diagnosis was established the patient’s con-
dition had grown progressively^ worse. He raised large
quantities of hemorrhagic sputum. He continued to
lose weight, his appetite was extremely poor, fatigue
and malaise were marked. He slept very little and
was very despondent. Pain in the right lower chest
and right shoulder appeared frequently. His tempera-
ture ranged from 98 to 103.8. There was a moderately
severe secondary^ anemia.

He was given alternating courses of emetine and
stovarsol. Within thirty-six hours after emetine therapy
was begun, his temperature became normal and re-
mained normal. The sputum decreased markedly dur-
ing the first four days and completely disappeared at
the end of tw^o weeks. Within a few days his appetite
became ravenous, in contrast to the former extreme
anorexia. He gained twenty-five pounds vdthin a month.
There were no toxic reactions from either drug. Eight
stool examinations and frequent sputum examinations
were negative for amebae. The sedimentation rate was
19, in contrast to 103 on admission. The leukocyte
count returned to normal. He w^as discharged Septem-
ber 16, 1938, as apparently cured and has remained
well. Serial roentgenograms showed complete resolu-
tion.

Case 2. — A white man, aged fifty-four, was admitted
September 16, 1938, complaining of severe cough,
sputum, and pain in the right upper chest. In July,
1936, he developed severe diarrhea and the diagnosis
of amebic dysentery^ was established the followdng Oc-
tober. A course of emetine therapy was followed by
disappearance of all symptoms. He remained well until
October, 1937, when cough, sputum, fever and loss
of weight occurred. In January, 1938, he had pain in
the right upper quadrant of the abdomen. A presump-
tive diagnosis of liver abscess was made and a second
course of emetine was given. He responded imme-
diately’ and remained well until July, 1938, when a re-
lapse occurred. Severe cough and sputum, pleuritic-
like pain below the right clavicle, night sweats and
fever were present. During the next tv\'0 months ex-
tensive, all-inclusive diagnostic studies were carried out
at one of our large national clinics. They concluded
there was no relapse of the amebiasis, but tubercle
bacilli were found in the sputum and although the chest
films were clear, they advised sanatorimn care.

289

AMEBIASIS— SHERMAN AND WEINBERGER

Fig. 1. Case 1. March 17, 1938. Right diaphragm elevated
full interspace higher than left.

Fig. 2. Case 1. July 5, 1938. Dense homogeneous shadow
obscures the lower one-quarter of the right lung field.

Fig. 3. Case 1. August 2, 1938. Pneumoperitoneum present.
Right lobe of liver widely adherent to diaphragm. Dense homo-
geneous mass involves right lower lung field.

Fig. 4. _ Case 1. October 14, 1938. Complete clearing of for-
mer density at right base except for opacity due to retained
lipiodol.

290

Jour. M.S.AI.S.

AMEBIASIS— SHERMAN AND WEINBERGER

Fig. 5. Case 2. September 16, 1938. Both lung fields clear.
Slight elevation of right diaphragm.

The physical examination, aside from evidence of
weight loss, was within normal limits. The chest roent-
genograms were clear. Direct smears, concentrates and
cultures of the sputum were negative for tubercle
bacilli. Bronchoscopic and lipiodol studies were nega-
tive. Three stool examinations were negative for
amebae. The sedimentation rate (Westergren) was 105
mm. The blood Kahn was negative. A pneumoperi-
toneum showed the liver to be widely adherent to
the right diaphragm and the flat film of the abdomen
suggested an enlarged liver. The icteric index was
3 and 8 on two occasions. There was a moderately
severe secondary anemia and a moderate leukocytosis.

A diagnosis of amebic abscess of the liver was made.
During the two months prior to admission he had
received continuous specific therapy to the point of
toxicity. It was felt that further administration of
emetine was contraindicated for the time being. Dur-
ing the next six weeks he improved clinically, but the
fever ranging from 99 to 103.6 persisted. In November
emetine was again given, alternating with stovarsol.
Within thirty-six hours his temperature was normal
and remained so for twelve days. Three courses were
given. The last course failed to bring about any change.
Daily fever persisted. Roentgenograms of the chest
one month after admission showed the right diaphragm
to be elevated two interspaces. Toward the end of the
third month he complained of palpitation and dyspnea
at rest. Examination revealed auricular fibrillation, con-
firmed by electrocardiogram. There was no edema. He
was digitalized. Surgical intervention was advised, but

Fig. 6. Case 2. September 29, 1938. Pneumoperitoneum.
Right lobe of liver widely adherent to diaphragm. Marked en-
largement of liver and elevation of right diaphragm.

he returned home January 13, 1939. His condition
grew worse. During the first week in March, 1939,
he became critically ill and was admitted to a large
general hospital in Detroit, where he died March 11,
1939. An autopsy was performed. The pertinent find-
ings are given here.

The liver margin extended 15 cm. below the coastal
margin. The right dome of the diaphragm reached
the level of the third intercostal space. The heart
was normal. The right lung weighed 920 gms. The
right lower lobe was large, consolidated and airless.
The cut surface was granular and microscopically the
picture was that of a lobar pneumonia. There was no
gross or microscopic evidence of tuberculosis. The
liver weighed 5,200 gms. and was enormously enlarged
by a bulging mass occupying the entire right lobe.
A quantity of thick creamy, gelatinous matter was
aspirated from this large solitary abscess which meas-
ured 20 cm. in diameter. After removal of the cyst
the liver weighed 2,720 gms. Sections from the ab-
scess wall showed amebae. No ulceration of the gastro-
intestinal tract was found and no amebae seen in sec-
tions of the large bowel.

Comment

Amebiasis is a widespread and common dis-
ease. Liver abscess is the most common com-
plication of the disease, but it is less generally
appreciated that pleuro-pulmonary complications
are frequently present but often not recognized

April, 1941

291

REQUIREMENTS IN PREGNANCY— MUSSER AND SODEMAN

during life. Thirteen per cent of cases of ame-
biasis develop pleuro-pulmonary complications.

There is no other known type of abscess of
the lung that responds at once so dramatically
to specific therapy as does amebic abscess. If
the diagnosis is suspected and the amebae are
not found, a therapeutic trial of emetine and
stovarsol will bring about an astounding im-
provement if amebiasis is present.

Not all cases of amebiasis with liver abscess
are cured by specific therapy. The usual initial
response to treatment may be obtained, but may
be followed by relapse in spite of adequate treat-
ment. This is illustrated by our second case,
in which an unusually large solitary amebic liver
abscess was found at autopsy. It is evident that
surgical drainage should have been done when
the early response was followed by relapse.

Amebiasis should be considered in the differen-
tial diagnosis in every lung abscess of the lower
half of the right lung. If there is no clear his-
tory suggesting amebiasis, diagnostic studies
should include the induction of pneumoperi-
toneum. This procedure gives reliable evidence
of any attachment between the right lobe of the
liver and the right hemidiaphragm, as well as
the actual size of the liver. Amebic abscess of
the liver is practically always located in the
right lobe. If this evidence is suggestive, specific
therapy is justified and indicated. Our first case
illustrates the dramatic response to treatment.
A tentative diagnosis of pulmonary tuberculosis
had been made in both cases before admission to
the sanatorium.

Conclusions

1. Two cases of amebic liver abscess with
pleuro-pulmonary symptoms and complications
are presented.

2. One case of lung abscess due to amebiasis
is discussed.

3. The difficulties in the diagnosis are out-
lined.

4. Treatment with emetine and stovarsol fre-
quently results in a dramatic cure, as in the first
case discussed.

5. A case of large solitary amebic liver ab-
scess without evident pulmonary disease but char-
acterized by distressing cough, sputum and dysp-
nea is presented.

6. When emetine and stovarsol and related
drugs fail in a known case of amebiasis, the pos-
sibility of a large solitary abscess must be con-
sidered and surgical drainage undertaken.

Bibliography

1. Craig, Chas. D. : Amebiasis and Amebic Dysentery. Spring-
field: Chas. C. Thomas, 1934.

2. Oschner, Alton, and Debakey, Micheal: Pleuro-pulmonary
complications of amebiasis. Jour. Thoracic Surg., 5:225,
1936.

3. Brown, Philip W., and Hodgson, Coren H. : Late results

in treatment of amebic abscess and hepatitis of the liver.
Amer. Jour. Med. Sci., 196:305, 1938.

4. Keeton, R. W., and Hood, Marion; Pulmonary disease sec-
ondary to amebiasis. Med. Clinics North Amer., 23:22:1,
1938.

Vitamin and Mineral

Heqnirements in Pregnancy"^

By J. H. Musser, M.D. and W. A. Sodeman, M.D.
New Orleans, Louisiana

John H. Musser, M.D.

University of Pennsylvania, B.S.
1905, M.D. 1908. Practiced internal
medicine until the War, when he spent
two years in the Army. After return-
ing to Philadelphia he became Associate
in Medicine at the University of Penn-
sylvania and on the staff of three of
the local hospitals. In 1925 he came to
Tulane as Professor of Medicine, where
he has been ever since. He also is
Senior Visiting Physician at the Char-
ity _ Hospital, New Orleans. Has at
various times been president of the
American College of Physicians, and
vice president of the American Medical
Association. At present is on the Amer-
. . ican Board of Internal Medicine, and

the Council on Medical Education and Hospitals of the A.M.A.

" An adequate diet is one which contains a suf-
ficient quantity of the factors necessai*}' for
proper growth, maturation, reproduction, and
maintenance of good health. The very definition
of an adequate diet, therefore, takes into con-
sideration the state of pregnancy and associates
intimately the possibility of deficiency disease
with pregnancy.

The inability of a patient to satisfy her bodily
nutritional needs may arise in many ways, but
for clinical purposes, such patients may be placed
in one of three categories. The first includes
those ingesting inadequate quantities of one or
more of the essential dietary’ factors. This may
arise from many causes ; for example, economic
difficulties, faddism in diet, psychic states, dys-

*From the Department of Medicine, School of Medicine,
Tulane University of Louisiana, New Orleans, Louisiana.

Presented at the Seventy-fifth Annual Meeting of the Michigan
State Medical Society, Detroit, September 25, 1940.

Jour. AI.S.M.S.

292

REQUIREMENTS IN PREGNANCY— MUSS ER AND SODEMAN

pepsia, and anorexia due to disease. The second
comprises those ingesting these factors in
amounts which are usually adequate, but with
the presence of some disease within the body
which interferes with their proper utilization.
The development of pellagra in chronic amebia-
sis and of hemorrhage in obstructive jaundice
are examples of such states. The third com-
prises those receiving an inadequate intake of the
essential dietary factors because of acutely or
suddenly changed requirements. While this
group is really a subdivision of the first above,
clinically it is well to consider it as a separate
division, for the usual normal diet may be taken,
but the bodily requirements have changed.

A person may have ingested and utilized a
diet which, for long periods of time, has been
adequate, at least to prevent the development
of symptoms. Then, some new state, such as
hyperthyroidism, tuberculosis, or pregnancy,
may appear and increase the need for certain
dietary factors without sufficiently increasing,
or at times actually decreasing, the appetite
and desire for food. The individual may con-
tinue to ingest the diet previously taken and
previously adequate, a diet which for the new
state is no longer adequate and symptoms and
evidences of subnutrition may arise.

In pregnancy the patient may fall into any one
or all three of these categories either from in-
cidental conditions or those directly related to
the pregnancy itself. The dangers of the third
group are always present, and those of the first
and second frequently develop. Increased re-
quirements without increased desire to raise the
intake of food is operative to some extent in all
pregnancies whether normal or abnormal. Preg-
nancy itself may, for reasons not always clear,
change the patient’s desire for food, or cause the
development of unusual dislikes and cravings,
which may eventuate in an inadequate diet. Tox-
emic states may do the same thing. Inadequate
utilization of an adequate diet again may arise
not only from incidental causes but directly from
the pregnancy; toxemia and vomiting of preg-
nancy, for example.

It is clear that in all pregnancies the phy-
sician must be on the alert for dietary defi-
ciency. A careful dietary regimen must be

carried out by the pregnant woman in order
to prevent the occurrence of deficiency disease.

The specific dietary needs of the body are not
entirely known, but in general the known re-
quirements may be listed as follows : ( 1 ) calo-
ries, (2) protein, (3) water, (4) minerals, (5)
vitamins. Palatability, satiety value, proper resi-
due, and digestibility are also important. All
of these groups require consideration in the diet
of the pregnant woman. •

Caloric Needs

Caloric needs are supplied by carbohydrates,
fats, and to some extent by proteins. In adults
these requirements are usually judged by the
physician and patient by the body weight. The
dietary is adjusted to bring the patient’s weight
to optimum levels, and when sO' adjusted intake
is maintained at a level necessary to maintain the
weight. In pregnancy, however, there is a physi-
ologic gain in weight, and caloric intake must be
increased to take care of this increased require-
ment. With a tendency toward obesity and with
advice to “eat plenty,” including milk and other
high calorie food, the patient may gain weight
excessively, and only too frequently a gain in
weight persists after delivery. The cause for
such persistence is not clear and may lie in
changed endocrine relationships, but it is only
too true that many women increase in weight
with each succeeding pregnancy.

One may ask what the normal weight gain in
pregnancy is, in order that the woman may ad-
just her caloric intake on the basis of weight
gain. Dieckmann and Brown® have found the
average weight increase in pregnancy to be 9.7
kg. (21 pounds) with a standard deviation of
4.3. In treating a woman whose weight is
optimum at conception, Dieckmann and Swan-
son’’ restrict total weight gain to 7.5 kg. (16.5
pounds), which is equivalent to the weight of
the fetus, placenta, amniotic fluid, and the ma-
ternal physiologic changes. Weight increases
little in the -first trimester when growth of the
fetus is small. As pregnancy progresses to the
second and third trimesters, increased demands
of the fetus are apparent. This is reflected in
many ways, such as the rise in the basal meta-
bolic rate® which progressively increases through
these two periods. In the last trimester the fetus
practically triples in weight. In the second tri-

April, 1941

293

REQUIREMENTS IN PREGNANCY— MUSSER AND SODEMAN

mester definite weight gains appear, approxi-
mately 0.5 pound per week, to increase to 2 or
more pounds per week in the third trimester. As
labor approaches, there is generally a loss in
weight. From the second trimester on, partic-
ularly at the fourth to fifth month, the diet
must be increased and carefully balanced to take
care of the caloric needs as well as the increased
protein, vitamin, and mineral requirements. In
the underweight patient, weight gains exceeding
those stated above* are desired, the amount ex-
ceeding 20 pounds depending to some extent
upon the degree of subnutrition.

No discussion will be given here concerning
the use of carbohydrates as the basis for certain
patterns of treatment in vomiting and toxemia
of pregnancy.

Although the basal metabolism returns to
normal levels following delivery, the caloric de-
mands of the mother continue at a high level,
even somewhat higher than in pregnancy itself,
because of the production of milk. In the human,
the caloric value of milk approximates 700 cal-
ories per 1,000 cc. In addition, an adequate in-
take of other nutritional elements entering milk
must be supplied. These will be mentioned be-
low. Likewise, certain nutritional factors are
deemed necessary to stimulate an adequate pro-
duction of milk, particularly fats, protein, vi-
tamin B, and adequate fluids up to certain
limits.

Proteins

Proteins supply the nitrogenous products,
amino acids, essential to the structure of cells.
They are important in water balance as well. In
pregnancy adequate protein intake is thought
also to increase milk production and prevent the
development of certain anemias. Inadequate
protein intake in pregnancy has been suggested
by the group at Ann Arbor as the cause of mild,
and possibly also severe, macrocytic anemia in
pregnancy.^ Excluding pregnancy, protein re-
quirements are usually given as 54 to 1 gm. per
kilogram body weight per day. The value varies
with the quality of the protein, that of animal
source, gelatin excepted, usually supplying the
essential amino acids with greater abundance
than that of vegetable origin. A large group of
individuals of average means in this country in-
gests up to 100 gm. of protein daily, a more than
adequate supply. But a large group of individu-

als of limited means receives an inadequate or
borderline intake of proteins. Inexpensive diets
are essentially carbohydrate diets, and the re-
striction of lean meats, fowl, fish, eggs, and milk
in the diet leads to protein inadequacy. In preg-
nancy such patients face an added shortage, for
fetal and uterine growth, as well as other changes
in the maternal organism, increase the nitrogen
requirements, and increase, therefore, the daily
protein requirements. There are estimates that
2,200 to 2,800 gm. of protein are stored in preg-
nancy. One finds estimates of daily needs ranging
from 70 to 119 gm. In comparison with the usual
requirement of ^ to 1 gm. per kilogram body
weight for the average individual, the pregnant
woman would need 1.5 up to possibly 2 gm. from
the fifth month on. In the period of lactation
a high protein intake is considered of particular
importance not only because of protein needs in
milk, but to stimulate milk production.

Manipulation of the protein intake in control
of toxemias of pregnancy is merely mentioned
here to emphasize the fact that protein restric-
tion and feeding play a part in the pathologic as
well as in the physiologic needs of pregnancy.

Water

Changes in water balance occur physiologically
in pregnancy. The hydremia, resulting in re-
duced hemoglobin and erythrocyte values, is well
known. However, adequate supplies of water
are usually of little concern in physiologic states
because of free access to it. The same is true of
pregnancy unaccompanied by pathologic condi-
tions. The pregnant woman is usually admon-
ished, however, to drink plenty of water, par-
ticularly in the later, stages of pregnancy, for
water intake at that time is thought to be im-
portant in the quantity of milk supplied in lac-
tation.

Minerals

Mineral substances perform bodily functions
essential to life and to proper nutrition. Many
of the minerals necessary in small amounts are
widely distributed in nature and occur in suffi-
cient abundance to make them of little clinical
importance except in rare instances. This is
true of copper, zinc, aluminum, magnesium, co-
balt, and nickel. Others, however, such as cal-
cium, phosphorus, iron, and iodine, are often re-
quired in quantities which exceed the supply and

294

Jour. M.S.M.S.

REQUIREMENTS IN PREGNANCY— MUSSER AND SODEMAN

become of extreme clinical importance. This is
particularly true in pregnancy where require-
ments are increased, for the fetus must obtain
all its mineral needs from the mother.

Calcium and Phosphorus. — Clinical examples
indicate only too clearly that the fetus exerts its
demands upon the mother for calcium and phos-
phorus even in the face of marked deficiency in
the mother. Adequate maternal supplies® pro-
duce highest grades of fetal bone calcification.
Deficient calcium supplies in the diet, together
with deficient maternal stores, lead not only to
demineralization of the maternal bones with os-
teomalacia’^® but may eventuate in fetal rickets.
Outside pregnancy, the daily calcium and phos-
phorus requirements are usually given as 1 to
1.5 gm. and 0.9 gm., respectively. In pregnancy,
the respective estimates are 1.3 to 1.8 and 1.4 to
2.0 gm. These requirements are felt in the latter
half of pregnancy. The newborn contains 24 to
30 gm. of calcium and 14 gm. of phosphorus,
over half of which is deposited in the last two
months.® Any remarks concerning calcium and
phosphorus requirements postulate an adequate
source of vitamin D (q. vide).

The best dietary sources of calcium and phos-
phorus are milk and milk products. A quart of
i milk contains 1.2 gm. of calcium and 0.9 gm. of
I phosphorus. Phosphorus sources are adequate in
I most dietaries in this country. Important sources
other than milk include beans, egg yolk, cheese,
whole wheat, beef, oatmeal, nuts, and prunes.
Calcium sources are often deficient, however.
Aside from milk, other foods high in calcium in-
clude egg yolk, molasses, clams, certain greens,
such as dandelion and turnip tops, figs, filberts,
and almonds. Green vegetables contain fair
amounts, but much of their calcium is not in
utilizable form because of the presence of oxa-
lates. Milk and milk products stand out, there-
fore, as the chief dietary sources, and at least
a quart per day should be included in the dietary
of the pregnant woman, even if calcium salts are
added. The latter, if used, should be given in
large dosage before meals or with dilute hydro-
chloric acid.

During the period of lactation at least one
quart of milk, and preferably a quart and a
half, should be ingested daily along with a
diet adequate from other standpoints to insure

a supply of calcium and other minerals. Even
under these circumstances, without cod liver
oil, positive calcium balance may be impos-
sible.

Iron. — The daily iron requirement for the av-
erage adult is usually placed at 15 mg. This
same figure has been given for pregnant women,^
but others have found higher values necessary.
The fetus draws upon the mother for the neces-
sary iron for hemoglobin production and re-
quires, it is estimated,^’® 250 to 500 mg., most of
which is taken into the fetus in the last trimester.
Since the fetus takes its requirement for blood
formation despite a deficiency in the mother, the
mother will become anemic and the child will
be born with normal red blood cell and hemo-
globin values for the newborn. However, the child
may not, under those circumstances, store the sup-
ply of iron needed for the first year of life and
may develop anemia before the end of the first
year. With inadequate maternal supply of iron,
one may see that fetal demands hasten the de-
velopment of iron deficiency anemia in the moth-
er, and repeated pregnancies, particularly, may
be important in the development of anemia.

When allowance is made for the hydremia of
pregnancy, already discussed, anemia, particular-
ly of the h}q>ochromic variety, is very common.
Although it occurs frequently in all economic
groups, indicating the existence of causative fac-
tors other than dietary intake, it definitely varies
with the economic status. One of the factors
operative in all economic groups is the reduction
in gastric acidity in many patients, which, it is
thought, interferes with the proper absorption of
iron.

The well-rounded diet, particularly with lean
meat, parenchymatous organs, such as liver and
kidney, eggs, and leafy vegetables, supplies ade-
quate iron without the necessity of added iron
salts. Other foods rich in iron include dates,
figs, prunes, oatmeal, raisins, molasses, legumes,
and other fruits, particularly apricots, prunes,
and peaches. Doubtful intake of iron-containing
foods is an indication for blood check-ups, which
should be done routinely on several occasions
during pregnancy in any event. Where correc-
tion of the diet cannot be relied upon, and where
hypochromic anemia develops as a result of
defective absorption in spite of apparently ade-
quate intake, addition of iron salts is indicated.

April, 1941

295

REQUIREMENTS IN PREGNANCY— MUSSER AND S'ODEMAN

Iodine. — In areas in which iodine deficiency
in the ground water exists, the use of the usual
measures for prophylaxis current in those areas,
such as the use of iodized salt, suffices in preg-
nancy and may be necessary to prevent the oc-
currence of goiter in the newborn.

Vitamins

The vitamins of known clinical importance are
vitamins A, certain fractions of the Bg com-
plex, C, D, possibly E, and K. All of these have
clinical aspects of direct importance in preg-
nancy. Increased requirements are known for
all in which sufficiently accurate estimates of
needs have been made.

In the first half of pregnancy, little concern
need be given the requirements above those
usually necessary. However, in the latter half
of pregnancy, requirements are greatly elevat-
ed and this increased need is carried into the
lactation period, as will be indicated below.

Vitamin A. — Vitamin A is essential for proper
growth, proper vision, and the maintenance of
healthy epithelial structures. In experimental
animals, changes in the urogenital epithelium:
have led to difficult labor in the female and to
degeneration of the testes in the male. Prema-
ture labor, stillbirth at term, deficient milk sup-
ply in the mother, diarrhea in the newborn, and
death of the young, have also been observed in
animals. In contrast to such marked deficiency
produced experimentally, humans show general-
ly moderate deficiency and the effects on human
reproduction of such grades of deficiency as seen
clinically are not known. Equivocal results have
been reported in the treatment of human sterility
with vitamin A.®

The daily requirement of vitamin A for adults
is probably around 3,000 to 4,000 I. U. These
amounts are doubled for children and pregnant
women. The League of Nations Commission rec-
ommends 8,700 to 9,000 I. U. for pregnant
women. Many estimates of the daily require-
ment have been made on the basis of the dark
adaptation test, which is not universally accepted
as a satisfactory method for such measurements.

Since the average diet is often not satisfac-
tory for ordinary needs, it is evident that
the doubled requirement in the latter half
of pregnancy is not likely to be met by this

means. Special efforts must be made to in-
clude in the diet foods high in vitamin A,
such as greens, sweet potatoes, cream, cheese,
yolk, carrots, corn, squash, liver, apricots,
and peaches. Rancid fats destroy vitamin A
and the precursor, carotene. Their impor-
tance in food storage is unknown, but vege-
tables are best cooked rapidly without fat
meat. Supplements are desirable. Fish liver
oils are commonly used and supply vitamin D
as well. Carotene concentrates may be used.
The presence of chronic infections, such as
tuberculosis, or liver disease, and chronic diar-
rhea, increases the need for such concentrates.

In circumstances in which vitamin A defi-
ciency is likely, and pregnancy certainly is one,
care must be used in the administration of min-
eral oil. As shown at Ann Arbor, mineral oil
interferes with absorption of carotene even when
given in doses as small as 20 c.c. twice daily be-
fore meals, but, when necessary, may be given
safely as a single dose at bedtime or when vita-
min A is used as a source of the vitamin.

It has been pointed out^^ that marked vitamin
A deficiency in pregnancy may simulate toxemia
and that treatment with vitamin A produces dra-
matic results.

The increased vitamin A requirements do not
stop with delivery. The mother’s milk contains
considerable quantities of vitamin A which, of
course, must be added to the usual amounts
necessary for the mother’s normal bodily func-
tions at that time. The vitamin A content of
mother’s milk has been shown to vary with the
mother’s intake, but is without relationship to
the fat content. The average vitamin A content
has been found to be 300 I. U. per 100 c.c., which
for 800 c.c. per day, would total 2,400 I.U. The
need for a continued large supply for the mother
in the period of lactation is evident.

Vitamin — Here again, the daily require-

ment of this vitamin is markedly affected by
pregnancy. The League of Nations Committee
recommends 10 I. U. per 100 calories for adults,
increased to 20 to 30 I. U. in pregnancy. Other
estimates include 1 mg. (333 I.U.) for each
3,700 non-fat calories. Clinical evaluations of the
American diet indicate that many people live on
diets borderline in vitamin B^ adequacy. Since
pregnancy increases the requirement, and may

JouK. M.S.M.S.

296

REQUIREMENTS IN PREGNANCY— MUSSER AND S'ODEMAN

:at times predispose to a reduced intake, one can
see that vitamin deficiency is not unlikely in
I pregnancy, and so-called gestational polyneuritis
i is considered by some to be almost exclusively
an expression of deficiency. One often thinks
of beriberi as a rare or unusual disease, but if
there is included in the syndrome those patients
in whom the diagnosis is masked by such terms
as gestational, diabetic, alcoholic, or metabolic
neuritis, and the polyneuritic manifestations of
sprue, celiac disease and pellagra, one sees that
beriberi is not infrequent.

One should not wait for gestational poly-
neuritis, however, to suspect vitamin de-
ficiency in pregnancy. The dietary history may
be helpful and, as with many of the other
vitamins of clinical importance, there are
vague symptoms and signs which occur in
lesser degrees of deficiency. Mild deficiency
is by far the most frequent, although usually
not characteristic enough to lead to a diag-
nosis on the basis of symptoms alone. These
symptoms, which include burning paresthesias
of the feet, heaviness and tenderness of the
extremities, ease of fatigue, pains, reflex
changes, anorexia, dyspepsia, and constipation,
may lead to erroneous diagnoses, such as neu-
rasthenia, and with the variety of vague com-
plaints to which the pregnant woman is heir,
may be lightly dismissed as “natural” or “to
be expected in pregnancy.”

The other vitamin deficiencies in their earlier
stages also produce non-specific features, and we
want to emphasize a consideration of these symp-
toms in the light of malnutrition, for it is only
by considering the possibility of malnutrition that
their nature may be recognized and proper treat-
ment instituted.

With increased requirements of vitamin Bj,
treatment of mild deficiency, or its prevention,
consists of the elimination of vitamin poor foods,
such as crackers, pastries, candy, syrup, and rice,
from the diet, and the addition of thiamin rich
foods, such as seeds, lean pork, milk, liver and
other internal organs. Cooking methods destroy
some vitamin B^. Where doubt arises as to an
adequate intake of vitamin B^, supplements of
brewers’ yeast or aqueous liver extract may be
given as well as the purified vitamin.

Again, lactation maintains the requirement of

vitamin B^ at high levels. In rats, requirements
as high as five times usual maintenance doses
have been found necessary in the nursing mother.
The vitamin B^ content of mother’s milk is in the
large part responsible. The vitamin B^ content
of human mother’s milk varies with the intake
through certain ranges, and study^^ shows that
levels above 25 gamma per 100 gm. are not ob-
tained by excessive dietary feeding.

Other Vitamin B Elements. — Rihofiofi/in and
nicotinic acid are of known clinical importance.
Aspects of riboflavin deficiency related to human
pregnancy have not been worked out to the
authors’ knowledge. One would assume that the
requirement is probably elevated, but the require-
ment outside pregnancy has not been settled as
yet. Nicotinic acid deficiency results in pellagra.
Although the Thompson-McFadden Pellagra
Commission found in a study in Spartanburg
Coimty, South Carolina, that the onset of pellag-
ra was relatively less frequent during preg-
nancy than at other times, in the early months
following delivery the incidence was excessive.
Records of others indicate that pellagra has been
precipitated by pregnancy and an increased re-
quirement of nicotinic acid is likely, although
details are not known. While the treatment of
pellagra is commonly carried out with nicotinic
acid, the possibility of the presence of multiple
deficiency demands an adequate diet from all
'Standpoints, concentrates rich in all factors of the
B complex, such as liver, liver extracts and
brewers’ yeast ; and foods rich in the B complex.

Pernicious vomiting of pregnancy is said to
have been successfully treated with preparations
of the entire B complex.

Vitamin C. — Vitamin C, or ascorbic acid, is
necessary for certain tissue respiratory functions,
and for the proper formation and maintenance
of intercellular substances, which accounts for
the hemorrhage and bone changes in deficiency.
Some have suggested that vitamin C deficiency
interferes with normal conception and acts as a
contributory cause of spontaneous abortion. The
daily requirement for normal adults is not
known. Estimates vary from 10 to 100 mg. daily,
averaging about 50 mg. (1,000 I. U.). It is
raised in conditions with elevated metabolism,
such as hyperthyroidism, pregnancy, lactation,
and infectious diseases, as well as in gastroin-

April, 1941

297

REQUIREMENTS IN PREGNANCY— MUSSER AND SODEMAN

testinal disease. In pregnancy estimates of daily
needs vary from 75 to 100 mg.

Such symptoms as mental sluggishness,
•weakness, gingivitis, ease of fatigue, muscle
and joint aches, anorexia, and anemia, are
more common than frank, classical scurvy,
symptoms which, in part at least, are com-
mon in normal pregnancy.

However, scurvy has been seen to develop in
pregnancy. Vitamin C is thought to have a
function in the healing of surgical wounds, which
may be of importance in the healing of the in-
juries of labor.

Vitamin C requirements can usually be sup-
plied satisfactorily by the diet. Such vitamin C
rich foods as citrus fruits and juices, green
peppers, strawberries, and many greens, are
the chief sources. Citrus fruits and tomatoes
stand out as readily available sources. With
proper canning and preserving, the vitamin con-
tent is maintained for long periods of time. Pro-
phylactically, such foods are sufficient in preg-
nancy. For active treatment in severe deficiency,
purified preparations, at times parenterally, may
be necessary.

Increased requirements of vitamin C continue
through lactation. Human milk has been found
to contain approximately 5 mg. ascorbic acid per
100 C.C., so that for a daily secretion of 800 c.c.
milk, 40 mg., equal to the usual average main-
tenance dose, are necessary in addition to the
mother’s usual needs. The vitamin C content of
human milk varies with the dietary intake and
is four to five times that of cow’s milk.

Vitamin D. — In infancy, vitamin D deficiency
results in rickets ; in the adult, in osteomalacia.
Symptoms of osteomalacia are few. Irritability,
undue sweating, pain in the lower back, and
stiffness of the legs are common complaints. The
child may be bom with evidences of calcium,
phosphorus, and vitamin D deficiency. Both
rickets and osteomalacia may be produced by
other factors which change the relationships of
calcium and phosphorus metabolism. In the dis-
cussion on calcium and phosphorus it was stated
that an adequate vitamin D supply was presup-
posed. Here, in discussing vitamin D, an ade-
quate intake of calcium and phosphorus is pre-
supposed, for added vitamin D does not insure

retention of calcium with intakes below 1.4 to
1.6 gm. daily.^°

The daily requirement of vitamin D is not
definitely known. In infants, 135 to 400 I.U. are
minimum and should be exceeded. In adults, the
requirement is unknown, for vitamin D is formed
in the body by solar irradiation of the skin. In
pregnancy, the requirement is elevated. Chief
sources are irradiation and the diet. Foods rich
in vitamin D are egg yolk, fish roe, liver, herring,
sardines, and canned salmon. Use of cod liver
oil or similar preparations is not generally routine
in pregnancy, but in many instances should be
advised in at least teaspoon doses, or solar irradia-
tion used instead. This is especially true in fre-
quent pregnancies for poor retention of calcium
and phosphorous may result, regardless of intake,
unless vitamin D is also given. Vitamin D is
strongly advised in all pregnancies and in lacta-
tion as well.

Calcium and phosphorous are necessar}' for
milk production and vitamin D requirements re-
main elevated during lactation. Milk intake has
been suggested in amounts as large as 1.5 quarts
per day at this time, but even then relatively few
women can prevent calcium loss without added
vitamin D.^° This is even more true with rapidly
succeeding pregnancies and lactation. Doses of
800 I.U. or more of vitamin D are suggested.

It should also be remembered that old vitamin
D deficiency of infancy may be important to the
patient after reaching maturity and becoming
pregnant, for maldevelopment of the pelvic bones
from rickets in infancy may lead to difficult labor

Vitamin E. — Vitamin E, identified as alpha-
tocopherol, is known to be necessary for fertility
and successful gestation in rats. There is no di-
rect proof that clinical deficiency produces such
an effect in man. The vitamin is widely distrib-
uted in nature, occurring in yeast, animal tis-
sues, germs of seeds, and particularly in lettuce
and other green vegetables.

There are many reports of successful treat-
ment of functional sterility and habitual abor-
tion in the human, so that when this does
take place, a trial of the vitamin is justified,
although the Council on Pharmacy and Chem-
istry of the American Medical Association has
not found sufficient proof to accept prepar-
ations for such use.

298

Jour. M.S.M.S.

1

1

APPENDICITIS— ROBINSON

Reports indicate that the use of wheat germ
I oil, the usual preparation, in habitual abortion,

, is attended by successful outcome in 75 to
^80 per cent of the cases. Yet similar results have
been obtained by other methods of treatment,
such as progestin and vitamin C, and in one re-
port, the spontaneous cure rate without any treat-
' ment was 78.4 per cent after one abortion.^ Such
results indicate that the efficacy of vitamin E in
these patients remains to be established.

Recent reports of the use of vitamin E in the
treatment of muscular and nervous disorders
' have thus far indicated no relationship to human
pregnancy.

i

' Vitamin K. — Vitamin K is essential to the
i proper formation of prothrombin, and a deficien-
j cy of the vitamin results in impaired prothrom-
I bin formation, impaired clot formation in the
j blood, and, finally, hemorrhage. Vitamin K oc-
curs in considerable amounts in alfalfa, kale,
spinach, dried carrot tops, tomatoes, oat sprouts,
egg yolk, soy bean oil and some other vegetable
oils. Bile is necessary for its proper absorption,
and this accounts for impaired absorption in ob-
structive jaundice, eventuating in lowered blood
prothrombin values and hemorrhage. Hemor-
rhagic disease of the newborn has been found to
occur upon the basis of vitamin K deficiency^®
and is corrected by the administration of concen-
trates of the vitamin or synthetic preparations,
such as 2-methyl- 1, 4-naphthoquinone, in 1.0 mg.
doses with 5 to 10 grains of animal bile salts. In
the newborn without hemorrhagic phenomena,
the prothrombin time is often prolonged, particu-
larly from the second to the fifth day. Interest-
ingly enough, this tendency may be corrected not
only by administration of vitamin K and bile salts
to the child, but by their administration to the
mother at the beginning of, or early in, labor.

Summary

We have presented a short sketch of the known
facts concerning the nutritional needs of the
mother when first she is carrying the baby in
utero and later when she is suckling it. We would
emphasize strongly the necessity of an ample,
well-rounded diet in order to preserve the well-
being of the pregnant woman, and in order to
have her give birth to a healthy child.

References

1. Bethell, F. H., Gardiner, S. H., and MacKinnon, F. : The

influence of iron and diet on the blood in pregnancy. Ann.
Int. Med., 13:91, 1939.

2. Browne, F. J. : A criticism of current views on the value

of vitamin E in habitual abortion. Proc. Royal Soc. Med.,
32:863, 1939.

3. Bushnell, L. F. : Vitamins in obstetrics. Surg. Clin. N.
America, 20:249, 1940.

4. Coons, C. M. : Iron retention by women during pregnancy.
Jour. Biol. Chem., 97:215, 1932.

5. Coons, C. M., and Blunt, K. : The retention of nitrogen,

calcium, phosphorus, and magnesium by pregnant women.
Jour. Biol. Chem., 86:1, 1930.

6. Dieckrnann, W. J., and Brown, I: The obstetric management
of patients with toxemia. Am. Jour. Obstet. and Gynec.,
38:214, 1939.

7. Dieckrnann, W. J., and Swanson, W. W. : Dietary require-
ments in pregnancy. Am. Jour. Obstet. and Gynec., 38:523,
1939.

8. Heath, C. W., and Patek, A. J. : The anemia of iron

deficiency. Medicine, 16:267, 1937.

9. Hughes, E. C. : Diet during lactation and pregnancy. Med.
Woman’s Jour., 47:19, 1940.

10. Jeans, P. C., and Stearns, G. : The human requirement of
vitamin D. in: The Vitamins. Chicago: American Medical
Association, 1939.

11. Macy, I. G., and Humscher, H. A.: An evaluation of ma-
ternal nitrogen and mineral needs during embryonic and
infant development. Am. Jour. Obstet. and Gynec., 27 :878,
1934.

12. Morgan, A. F., Haynes, E. G. : Vitamin Bi content of

human milk as affected by ingestion of thiamin chloride.
Jour. Nrtrit.. 18:105, 1939.

13. Rector, J. M. : Prenatal influence in rickets. 1. Fetal rickets.
Jour. Pediat., 6:161, 1935.

14. Ricketts, W. A.: Vitamin A deficiencies in pregnancy. Am.
Jour. Obstet. and Gynec., 38:484, 1939.

15. Shettles, L. B., Delfs, E., and Heilman, L. M. : Factors

influencing plasma prothrombin in the newborn infant.
Bull. Johns Hopkins Hosp., 65:419, 1939.

16. With, T. K., and Friderichsen, C. : Carotinoid and vita-
min A content of breast milk with special reference to
the effect of diet. Ugesk. Lsger, 101:1915, 1939 (abstr. in
Nutrit. Abstr. and Rev., 9:713, 1940).

Appendicitis

The Problem from an Edu-
cational Standpoint

By R. G. Robinson, M.D.
Detroit, Michigan

R. G. Robinson, M.D.

B.S. and M.D., University of Michigan,
1930. Attending Surgeon, Parkside and Edith
K. Thomas Hospitals. Courtesy Surgeon, Grace
Hospital. Member of the Michigan State Med-
ical Society.

■ Some ten thousand articles on appendicitis
are to be found in medical literature. Three
interesting statements appear, as a rule, in the
majority of recent publications on the subject.
(1) There are about 20,000 deaths annually from
the disease. (2) Eighty per cent of the deaths
are due to generalized peritonitis. (3) There
could be a 75 per cent reduction in mortality if
patients were seen early enough and the proper
treatment immediately instituted. These three
statements formulate a challenge which we as a
profession must face. There are two aspects to
the problem. One involves lay education which
is now being carried on in an ever increasing
volume by means of radio, public lectures, and

April, 1941

299

I

APPENDICITIS— ROBINSON

to some extent through our schools. The second
aspect is that of the availability of efficient medi-
cal care.

The increasing death rate from appendicitis
suggests that organized medicine may well seek
further avenues through which the simple im-
portant facts of health and disease may be
brought to the public. From this standpoint,
appendicitis is one of many important common
diseases of which more should generally be
known. While it is true that we cannot over-
look the fine efforts already operative, yet we as
medical men note too long an interval between
the inception of the disease and medical con-
sultation. Likewise, abusive ingestion of ca-
thartics and complete lack of suspicion of the pas-
sibility of appendicitis by the laymen clearly in-
dicate a need for some more effectual approach
to our problem.

A Proposal

Our schools provide an excellent medium
through which health education may be extended.
This in itself is not a new idea but one whose
possibilities have not been fully utilized. Well-
designed programs of preventive medicine are
now doing excellent work. A simple course in
the lower grades and junior high schools, teach-
ing simple rules and precautions about health
and diseases, would not only have great intrinsic
interest but would undoubtedly save many lives.
Too many grade, high school and college gradu-
ates possess insufficient general medical informa-
tion to protect themselves against tragedies, such
as ruptured appendix. A recent survey by the
United States Office of Education showed that
less than 10 per cent of college students, other
than medical students, had taken any courses
pertinent to health or hygiene.

Curricula ought therefore recognize that gen-
, eral medical information, sufficient to make the
individual intelligently concerned about his body
as he is about his mind, is necessary. To be sure
there are now a few courses which may be
elected by the student. In other instances
courses in hygiene, etc.^ are required. These
are, however, altogether too limited in scope. A
great job in public health education could be
accomplished if there were compulsory courses
in grade schools, high schools and in colleges
which went beyond the usual physiologic and
hygienic limitations. A more intelligent public

would undoubtedly bring the patient to his phy- |
sician earlier. The effect on mortality rates gen- I
erally would be apparent over an adequate period |
of time. As physicians and guardians of the |
health of the public, it is our duty to see that
adequate courses are outlined and also that state
and local educational boards be duly petitioned.
This should, of course, be sponsored by our !
State Medical Society assisted by local County
Societies.

■!

The Second Consideration

From the standpoint of the operating surgeon
no plea for a broader educational effort, designed
to effect an earlier recognition of appendicitis,
could possibly be considered effectively stated r
without a word as to the responsibilities of the
corner druggist and finally the physician him-
self.

Too often the appendicitis patient presents
himself first to our friend the druggist whom he
induces to give him something for “stomach ache.”
And too often the something he procures is not
advice to see his family physician, but some
form of catharsis. Unquestionably all of us
have encountered time and again cases of drug !
store meddling of this nature. As physicians, it
is our explicit duty to duly censor such prac-
tices and emphatically discourage this form of
prescribing. No doubt a few lives could be
saved in this manner.

The practicing physician must ever have in
mind certain basic facts about appendicitis if
he is to render efficient medical care. It should
be his policy to catalogue these facts as rules

to this end. Let it be remembered that ap-

.1

pendicitis is an indefinite general term which
encompasses a number of clinically different
states in the progress of this disease. The phy-
sician must attempt to visualize from 1he data
at hand just what state the appendix is in. He ’
must, therefore, refine his diagnosis and classify I
his case. i

Classification

I. Acute Uncomplicated Appendicitis
II. Acute Complicated Appendicitis j

A. Gangrene |

1. Acute perforation i

(a) Local peritonitis

(b) Generalized peritonitis

300

Jour. M.S.M.S.

APPENDICITIS— ROBINSON

B.

(1) without ileus

(2) with ileus

2. With pylephlebitis

3. With liver abscess
Appendiceal abscess

III. Chronic Recurrent Appendicitis.

General Rules

1. Acute epigastric or generalized abdominal
pain with or without vomiting, which localizes
in the right lower quadrant should be considered
appendicitis until proven otherwise.

2. Constipation is generally the rule with ap-
pendicitis.

3. Never prescribe a cathartic or a sedative
for abdominal distress until acute surgical ab-
domen has been eliminated.

4. Repeated physical examinations, white cell
counts, differentials. Schilling Indices, and at-
tention to pulse and temperature curves are nec-
essary to ascertain the progress of appendicitis.

5. Generally, a temperature of 101 degrees
or above with a pulse rate of 110 or above in
acute appendicitis of more than twelve hours’
duration means complications are present or
eminent.

6. The prognosis of appendicitis in the ex-
tremes of life is always poorer.

7. The treatment of appendicitis is surgical
and always demands the immediate services of
a competent surgeon.

•8. Do not classify appendectomy as a simple
operation.

9. Whenever the diagnosis is uncertain and
the possibility of appendicitis must be considered,
three points must be determined :

(a) Is the case surgical?

(b) Is watchful expectancy reasonably safe?

(c) Do the findings justify operation?

These important questions must be worked

out by competent observers in consultation. In
every case the patient should receive that treat-
ment which will safeguard his life.

Conclusions

Fifteen thousand deaths could be prevented
yearly by more effective education as to the facts
about appendicitis. Our present educati
gram could be made more effective>^^^fc§^(lary
schools and colleges included in curricula

simple informative courses desij
individual reasonably intelligent

the common illnesses which affect the human
body. The move for greater dissemination of
medical knowledge through the school system
should be the problem and duty of our State
Medical Society. This fine opportunity for real
effective service should not be overlooked.

If the physician desires to give competent serv-
ice to his patient he must mentally visualize
what is transpiring at any given moment; he
should catalogue his information and formulate
working rules wherever possible. He must con-
sult without hesitancy with his confreres and al-
ways urge the institution of that treatment
which will most effectively avoid tragedy.

3751 31st Street.

Vitamin Content of Citrus Fruits

The following table shows approximate amounts of

the substances listed in Florida oranges, g

rapefruit and

tangerines :

Oranges

Grapefruit

Tangerines

per 100 c.c.

of freshly expressed juice

Vitamin C.

50 mgm.

40 mgm.

35 mgm.

Vitamin B.

20 Sherman

20 Sherman

No data

Vitamin G.

units

Present

units

Present

No data

Vitamin A.

Present

No data

Present

Calcium

8 mgm.

9 mgm.

13 mgm.

Phosphorus

17 mgm.

15 mgm.

12 mgm.

Carbohydrate

11.6 gm.

10.1 gm.

. .

Citric Acid

0.9 gm.

1.31 gm.

0.75 gm.

Potential

alkalinity

5 C.C.N/

4.5 c.c. N/

I

4.5 c.c. N/

alkali

alkali

alkali

Fuel value

52 calories

45 calories

• — From Citrus Fruits and Health, by Florida Citrus
Commission.

OF

led to rrlakejtRb
ibout sonre'''€>f

^OOi.

Social Aspects of Tuberculosis

The prevention of tuberculosis is not merely a pub-
lic health problem but also a powerful social and
economic factor which affects the economic structure
of the entire nation.

“At a time when all values have tumbled and num-
erous assets have to be classified as frozen, the health
and productivity of the people remain the outstanding
and most tangible resources of a nation and it would
be the short-sighted policy of the penny-wise and dol-
lar-foolish to curtail preventive health measures for
the sake of economy,” says Dr. Karl Fischel of
Saranac Lake.

The tuberculosis problem is closely linked with
other momentous issues of the day, and the tubercu-
death rate of the future is, therefore, bound to
by the solution of other problems, be it
unemplcrj^ent, inflation, commodity prices or disarma-
ment.— vjFfqm an essay awarded the Leon Bernard
MefnoriaPpdze for 1938 by the International Union
Against Tubferculosis) Fischel, Karl, Bull, de I’Union
contre Tubefc., 1939, 16.

OF M

April, 1941

301

One Examination
for

Selectees

A thorough conscientious examination of every ap-
plicant is the first and most important requisite
of an insurance company before it accepts a risk.

The thousands of selectees for the peace-time army
are being examined by civilian draft boards in each
locality. This peace army is to be composed of per-
fect men who can stand the strain of a year’s training
without physical or mental breakdown.

If after induction in army activities by an army
board, a soldier manifests a physical or mental disease
acquired prior to induction, and must be discharged,
he is a liability on our government. In the past war,
the cost rose and mounted into the millions of dollars.
The induction boards therefore are rejecting a higher
percentage than are the civilian boards. They are
held responsible and must trim down cases which
local doctors of medicine certify as perfect.

Between the time the selectee is placed in 1-A and
the moment he reports to the induction board, many
things may happen to his physical or mental condition ;
some are self-induced. The reports of the army
boards are sent back to the draft boards and the ex-
amining physicians may compare their diagnoses to
the rejection causes.

The ideal way to release the civilian doctors for
duty at home defense centers would be to use the
reserve officers who now compose the induction boards
as traveling examining boards, tO’ rotate them over a
given area, and to have them make one complete ex-
amination— after which the applicant is in the army.

Let us continue to do our part in this work, but if
it is to continue permanently, let us ask for a revision
of the laws, to increase efficiency.

President, Michigan State Medical Societ}'

☆

Preiident

aae

☆

Jour. M.S.M.S.

302

-K EDITORIAL >f

CANCER IN MCraGAN

■ At the request of The Journal, C. C. Little,
Sc.D., Managing Director of The American
Society for the Control of Cancer, Inc., and
former President of the University of Michigan,
has contributed a special statement on cancer
control in Michigan.

It is indeed gratifying to have such a dis-
tinguished authoritv compliment the advance
made in the state. The Cancer Committee of the
Michigan State Medical Society continues active
and progressive and deserves its full share of
credit for its part of the work.

“The record of the State of Michigan in the
field of cancer control is an excellent one,
comparing favorably with the highest stand-
ards of effectiveness attained in any of the
states.

“For the purposes of convenience the state is
divided into two areas, one including Wayne,
McComb and Oakland Counties, and, of course,
the City of Detroit, and the other comprising the
rest of the state.

“The organization of cancer control work has,
for the most part, been carried on in Michigan
by volunteer women under the direction of
cancer committees of the state and local medical
societies. This latter policy of medical supervi-
sion is insisted upon by the American Society
for the Control of Cancer which works through
its creation — the Women’s Field Army.

“Cancer is, of course, unique in that actual
individual participation of those interested in
the program of education must be obtained
and maintained if the campaign is to have any
value. Mere acquisition of information is not
enough. There must be follow-up and con-
stant pressure to see that individuals do not
ignore the advice contained in the informa-
tional material, which they receive.

“A series of eight Regional Assemblies of
Women’s Field Army officers and medical ad-

visors has just been completed and the society
has announced that the evidence is general that
the increase in percentage of patients coming
early to the doctors is country-wide and pro-
gressive. This means that the campaign to de-
feat the fear of cancer is already well in sight
of a victory, and that following the removal of
such fear we may expect that greater results of
education will make themselves felt.

“At all events, both the medical profession of
Michigan and the lay officers of the Field Army
who are cooperating with it are to be congratu-
lated for work already done and encouraged in
every possible way in the advancement of that
to be carried on.”

READ AND WRITE

" A great deal of criticism is voiced about the

voluminous writings of the profession.

This criticism is not warranted.

It is not the voluminous writing which
should be criticized so much as the volumin-
ous publication of these writings.

The value of a thesis is not primarily in the
publication thereof. To assemble the data neces-
sary to produce a scientific article requires much
reading and serious thought. It requires the in-
vestigation of many viewpoints and differences
of opinion. This reading cannot be superficial
and must be accompanied by a singleness of pur-
pose which impresses the material on the mind
of the writer. This data must be assembled in
logical order and the various view-points balanced
and weighed against each other. Then the ulti-
mate thought must be put in intelligible form.

Medical journals welcome the submission of
all manuscripts for review and are glad to pub-
lish them if they are of sufficient value and in-
terest to the reader. But even though the paper
never appears in print that one man has been
well repaid for his work, the interest of his
patients more completely satisfied and a better
physician is the result.

April, 1941

30^

IN MEMORIAM

DONT TELL THE WORLD

■ The other day the secretary of a western
Michigan county medical society made the
statement that the first time that one of his
members asked why laws unfavorable to the
medical profession were enacted by the legisla-
ture, “all hell will break loose.” He continued
his statement by detailing how he had pled with
his members to interview their local representa-
tives to the state government and in spite of
promises, not a single one had even broached
the pertinent subject to the legislators.

Of course, this situation is so common that
the secretary was not even commiserated.

You, and every other member of the Michi-
gan State Medical Society, are informed by
the secretary of your county society of all bills
bearing on medical subjects introduced in the
two houses. Usually every week or two your
representative will visit your district over the
week end or longer and will not only listen to,
but be considerably influenced by, your opin-
ion as to the value of these bills.

Don’t tell it to the world. Don’t grumble in
the doctor’s room. Tell it to your legislator.

Jllcmomtn

John F. Adams of Ann Arbor, Michigan, was
born February 16, 1867, at Woodville, Ontario, Canada.
He came to Michigan at the age of twenty-one, and
a year later, entered the College of Physicians and
Surgeons of the University of Illinois where he was
graduated in 1893. He engaged in practice at Mt.
Pleasant, Michigan, for a number of years, and twenty-
five years ago moved to Ann Arbor where he was an
active member of the profession until his death on
January 10, 1941.

George H. Belote, M.D., of Ann Arbor, was born
in 1894 in Centerville, Michigan. A student at the
University of Michigan in 1916, his studies were in-
terrupted by army service in the World War; he en-
listed in the headquarters troops of the 85th division
in July, 1917. He received his commission as second
lieutenant in 1918 and was honorably discharged in
1919. He returned to the University and was graduated
from the medical school in 1923. From 1923 to 1925
he was an intern at the University Hospital. He then
became instructor in the dermatology department. In
1928 he was named assistant professor and in 1930
was made associate professor of dermatology and
syphilology. Doctor Belote was a member of the Uni-
versity School faculty for seventeen years. His work
won him national recognition as an authority on
dermatology qypd syphilology. He died on March 11,
1941, after an illness of three weeks.

J. E. Bolender of Grand Rapids, Michigan, was
born at Hubbardson in 1885 and was graduated from
the University of Michigan Medical School in 1912.
He started his practice in Sparta where he remained
until he came to Grand Rapids, ten years ago. Dr.
Bolender died on January 9, 1941.

Arthur H. Burleson, M.D., of Olivet, Michigan,
was born September 19, 1861, in Quincy, Michigan,
and was graduated from the University of Michigan
Medical School in 1896. Doctor Burleson first started
practicing at Albion, a year later moved to Tekonsha,
where he remained until 1906, when he located in Olivet
and practiced there for thirty-four years. Doctor
Burleson was an Honorary Member of the Michigan
State Medical Society since 1932 and had served as
secretary of Eaton County Medical Society for a
number of years. He died December 17, 1940.

Don Bruce Cameron of Grand Rapids, Michigan,
was born in White Pigeon, Michigan, on Oct. 24, 1896.
He studied at Olivet college for three years and was
graduated from the University of Chicago with the
degree of bachelor of science. Following graduation
he enlisted in 1917 and later engaged in research work
at Walter Reed hospital, Washington, D. C. He later
entered the officer’s training camp at Camp Taylor and
was commissioned a lieutenant in the field artillery.
After the war Dr. Cameron entered Rush Medical Col-
lege and was graduated in 1922. He served his intern-
ship at St. Luke’s Hospital, Chicago, and in November
23, 1927, started practice in Sturgis, where he remained
until 1927 when he accepted an appointment as resident
surgeon at Butterworth Hospital. The following year
Dr. Cameron opened offices in Grand Rapids which he
maintained until he was forced to abandon them last
October because of ill health. He died January 17, 1941.

Kenneth W. Dick of Imlay City, Michigan, was
born April 17, 1886, in Ontario, Canada, and was grad-
uated from the Detroit College of Medicine in 1907.
He maintained a practice in Detroit for 18 years. In
1928 he moved to Carsonville, and in 1937 became a
staff member of the Home and Traim'ng School, La-
peer. He began practice in Imlay City in 1939. Doctor
Dick was vice president of the Lapeer County Medical
Society in 1940 and had been reelected for 1941. He
died January 25, 1941.

Thomas Jefferson Henty of Detroit, Michigan,
was born in 1861 in Ontario, Canada, and was grad-
uated in 1900 from Trinity Medical College, Toronto.
Doctor Henry was a member of the staff of Grace
Hospital and had maintained a practice in Detroit for
over forty years. He died December 24, 1940.

J. G. Huizinga of Holland, Michigan, was born in
1868 and was graduated from the University of Michi-
gan Medical School in 1890. Doctor Huizinga estab-
lished a practice in Holland and then went to Engle-
wood, a suburb of Chicago. While there, he served
as professor of ophthalmology at the former Chicago
Eye, Nose and Throat College. Later he practiced in
Grand Rapids and remained there thirty years. Some
ten years ago he returned to Holland. Doctor Hui-
zinga died in Lake City, Florida, on December 20, 1940.

Alexander H. MacPherson, M.D., of Grand Rapids,
was bom in 1880 at Grand Rapids and was graduated
from the University of Maryland at Baltimore. Doc-
tor MacPherson has practiced in Grand Rapids for
thirty-five years, except for the duration of the World
War when he served as medical chief of the Base
Hospital at Camp Grant, Illinois, with the rank of
captain. He died on March 7, 1941.

304

Jour. M.S.M.S.

>f YOU AND YOUR BUSINESS >f

ROSTER NUMBER

The annual directory of membership will be
published, as usual, in the May issue of The
Journal which goes to press April 10.

Physicians who have not as yet mailed their,
county and state medical society dues to their
county secretary are urged to do so in order
that their names may appear in the Roster Num-
ber of the MSMS Journal as members of the
Michigan State Medical Society.

MICHIGAN HOSPITALS AND
MEDICAL PAYMENTS PLAN

This voluntary agreement, entered into and
approved by the American Mutual Alliance, the
Association of Casualty and Surety Executives,
a group of Michigan insurance carriers, the
Michigan Hospital Association and the Michigan
State Medical Society, has been developed to
solve a most annoying problem : doctors and
hospitals have in the past experienced difficulties
in securing the payment of fees from patients
who have collected damages from persons caus-
ing their injuries, despite the fact that in such
cases a part of the patient’s financial recovery
actually was based on hospital, medical and sur-
gical expenses.

The voluntary agreement of the insurance car-
riers and associations, and the hospitals and med-
ical profession of Michigan is aimed to more
definitely assure hospitals and physicians of pay-
ment for their services to those individuals who
are injured in accidents and who, because of
their injuries, are indemnified by an %isurance
carrier.

In order that the insurance companies may
furnish the fullest cooperation (and for the hos-
pitals’ and physicians’ own proper protection),
physicians and hospitals are requested to notify
insurance companies promptly of any claim upon
which an order has been or may be issued.

Forms for the convenience of physicians and
hospitals have been devised and are available in
pads of 50 and 100 (25c and 50c respectively).
Signify Form 1, 2 Or 3 and the number desired
when writing the Secretary, 2020 Olds Tower,

Lansing. These forms were printed in the Feb-
ruary MSMS Journal, pages 126-127-128.

IN MICHIGAN, IT'S TWO YEARS

Statutes of limitations — another form of de-
fense in malpractice actions — were designed ‘‘to
prevent the imexpected enforcement of stale
claims, concerning which persons interested have
been thrown off their guard by want of prosecu-
tion” (Miller v. Calumet Lumber and Mfg. Co.,
121 111. App, 56) ; the various state legislatures
realizing, in enacting these laws, that time will
erase the best evidence by loss, destruction of
records, or death of witnesses, and that if there
is a just cause of action it will be begun at once.
—Samuel Wright Donaldson, A.B., M.D.,
F.A.C.R., The Roentgenologist in Court. Charles
C. Thomas, 1937.

CALL IT "THE BEAUMONT BRIDGE"

Whereas, Plans are in process for the construction
of a bridge from Mackinac City to St. Ignace, connect-
ing the two beautiful peninsulas which constitute the
State of Michigan, and

Whereas, The area in the vicinity of this great pub-
lic project is Scmctified by the research work and scien-
tific contribution of an Army doctor, William Beau-
mont, Doctor of Medicine, who, in 1833 at Fort Macki-
nac, with keen scientific insight and true medical inter-
est, made the first publication of physiology of diges-
tion. This work, done under tremendous difficulties,
was the most important on this subject to that date
and laid much of the foxmdation for future studies.
His studies were begun at an isolated military post in
the wilderness of Northern Michigan and completed
only by following up his patient and bringing him near-
ly two thousand miles to Plattsburg, New York. This
is one of the great dramatic episodes in the history
of medicine, and

Whereas, The contributions of Doctor Beaumont to
the science of medicine have saved imtold lives and
relieved the distress and pain of thousands of our
fellow beings, therefore, be it

Resolved, That the proper authorities be petitioned
by the Michigan State Medical Society to christen this
bridge structure in honor of William Beaumont, M.D.,
as a method of publicly recognizing this great physi-
cian for his contribution to the relief of human suf-
fering.

The above resolution was adopted unanimous-
ly by the House of Delegates of the Michigan
State Medical Society in September, 1940.

No more fitting and honorable name could be

305

Apru., 1941

YOU AND YOUR BUSINESS

given to the span between the Upper and Lower
Peninsulas of Michigan than “The Beaumont
Bridge.”

ASSOCIATION OF PHYSICIANS
AND CULTISTS

The following statement of policy was adopted
by the House of Delegates of the American
Medical Association in June, 1938, and by the
Michigan State Medical Society’s House of Dele-
gates in September, 1938 :

Many inquiries concerning the relations of the various
cults to the regular profession have been received. The
inquiries pertain particularly to the osteopath and the
optometrist. Some of our members are giving lec-
tures in osteopathic and optometric schools and ad-
dresses before their societies. Some members are as-
sociated by a common waiting room in offices with
them. Some members are by mutual agreement pro-
fessional associates principally in the field of surgery.
There are some instances of partnership in practice.
All of these voluntarily associated activities are un-
ethical. Such relations certainly do not “uphold the
dignity and honor of (our) profession” or “exalt its

86c out of each $1.00 gross income
used for members benefit

PHYSICIANS CASUALTY ASSOCIATION
PHYSICIANS HEALTH ASSOCIATION

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306

standards.” In case of emergency no doctor should
refuse a sufferer knowledge or skill which he possesses
to the sufferer’s harm but this is quite a different mat-
ter from that of a consultant or practitioner who by
consulting or practicing with him assists a cultist to
establish himself as competent and on the same basis of
medical knowledge as a doctor of medicine. By the very
nature of the education and training of each, a consulta-
tion with a cultist is a futile gesture if the cultist is as-
sumed to have the same high grade of knowledge,
training and experience as is possessed by the doctor
of medicine. Such consultation lowers the honor and
dignity of the profession in the same degree to which
it elevates the honor and dignity of the irregular in
training and practice. Practicing as a partner or other-
wise has the same effect and objection. Teaching in
cultist schools and addressing cultist societies is even
more reprehensible, for such activities give public ap-
proval by the medical profession to a system of heal-
ing known to the profession to be substandard, incor-
rect and harmful to the people because of its deficien-
cies. There hardly can be a voluntary relationship be-
tween a doctor of medicine and a cultist which is
ethical in character.

BENEHTS OF MEMBERSHIP

The Michigan State Medical Society and its
component county societies bring you many val-
uable benefits of membership, especially these of
a professional and educational character ;

1. Assurance of a high ethical standing for you in
the commun ty, the state and the nation, before
the public, the law, and the profession.

2. Postgraduate courses and lectures to keep ypu in
touch with medical progress and to improve pro-
fessional ability.

3. Your common interests safeguarded through the
vigilant work of democratically selected officers
who are men of your own kind: (a) who know
your problems and those of your patients; (b)
who serve generously without compensation ;
(c) who need and ask for your cooperation and
adv^.

4. Benefits accruing from the action of numerous
committees constantly working to advance your
interests as a physician in your community ; ma-
chinery solving problems of preventive and cura-
tive medicine which could not be worked out by
you as an individual, even with a great sacrifice
of time and effort.

5. Maintenance and constant improvement of stand-
ards of medical practice for the protection of
patients.

6. A monthly Journal of high quality with the latest
scientific literature, and general information im-
portant to you.

Jour. M.S.M.S.

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April, 1941

Say you sazv it in the Journal of the Michigan State Medical Society

307

-K

MICHIGAN’S DEPARTMENT OF HEALTH

HENRY A. MOYER, M.D,, Ccmimissioner, Lansing, Michigan

-K

RECORD LOW INFANT DEATH RATE

Michigan’s infant mortahty record for 1940 is the
best the state has had, according to provisional fig-
ures. Deaths of babies in their first year were at the
rate of 40.72 per 1,000 live births, a lower rate than
ever before. It was the third successive record.

If there had been 72 fewer deaths of infants, the
rate would have dropped under 40 for the first time.
Detroit’s rate has been under 40 since 1938. The
provisional rate for Detroit in 1940 is 38.14.

“In the last ten years, the infant death rate has been
cut a third,” says Commissioner H. A. Moyer, “and the
result is that in 1940, more than 2,000 babies lived who
would have died in 1930.”

The figures for 1940 and 1930 follow:

1940 1930

Births 99,139 98,882

Deaths under 1 yr. 4,038 6,213

Deaths per 1,000 live births 40.72 62.83

Commissioner Moyer said that prenatal care is de-
manded by more women than ever before, and that the
quality of medical care throughout pregnancy and at
birth is better than ever. The Department’s bureau of
maternal and child health, established in 1920 when the
infant death rate was two and a half times what it is
today, has worked actively with physicians for years in
an effort to bring greater safety and ease to mothers
at birth and to improve the care of both m.other and
baby afterwards.

In the last three years, 126 physicians have taken two-
week leaves of their practices to modernize their
obstetrical work in postgraduate studies at the Univer-
sity Hospital at Ann Arbor. The studies have been
sponsored by the Department and have been available
without charge to physicians, on the endorsement of
their county medical society.

Furthermore, the Department has cooperated with
the Michigan State Medical Society, the University of
Michigan, and Wayne University in taking into the
field postgraduate material through lectures. One
pediatric and two obstetric consultants from the De-
partment’s staff are also in the field, at the call of
physicians.

Michigan is not yet in the group of states having
the lowest infant death rates. The latest comparative
figures are the provisional census rates for 1939, which
show 14 states under a rate of 40. The lowest rates
in 1939 were: Minnesota 35.4, Connecticut 36.1, Ne-
braska 36.5, Oregon 36.6, Washington 36.7. Washing-
ton was the first state to achieve a rate under 40, when
it had a rate of 38.8 in 1933.

Nationally, the infant death rate has been dropping
for several years. It went below 50 for the first time
in 1939, when it was 48.0, compared with 51.0 in 1938.

NEAR EPIDEMIC OF MEASLES

As expected, measles cases in Michigan are now
being reported in epidemic numbers. The reports from
physicians are coming from nearly all sections of the
state.

Prediction of 1941 as an epid^ic year had been made
because of the three-year cycle evident in recent years.
In 1935 and again in 1938, 80,000 cases were reported.

Every physician in the state has received or will
receive a new measles pamphlet prepared especially
for medical men. It is called “This Is a Measles
Year, Doctor!” The preparation of authoritative ma-
terial on prevention and treatment of measles and

its complications was made with the cooperation of
the Michigan branch of the American Academy of
Pediatrics and the Child Welfare Committee of the
Michigan State Medical Society.

The _ new pamphlet is eight p^es, folded five by
eight inches in size, and it carries a tab for ready
reference in a file. In counties with full time health
departments, distribution of the pamphlets is made
through the health officer. In other counties, copies
were mailed, as addressed by the executive office of
the State Medical Society.

Measles cases reported in February totaled 9,510.
This compares with February reports in previous epi-
demic years as follows: February, 1938, 10,473; Fel>

ruary, 1935, 4,617. The January cases in 1^1 totaled
6,485, a much larger total than the January reports of
either 1938 or 1935, when the figures were 3,056 and
1,264, respectively.

The big months in the previous two epidemic years
were March, April and May, when 15,000 to 25,000 cases
a month were reported.

NEW HIGH RECORD IN BIRTHS

Births in 1940 totaled 99,139, provisionally, five per
cent more than in 1939, and only a few hundred under
the all-time high of 99,940 births in 1927.

The birth rate, calculated on the final census popula-
tion for the state of 5,256,106, is 18.86 births per 1,000
population. This is the highest birth rate since 1930,
when it was 20.4.

Births for selected years follow:

1940—99,139
1939—94,432
1938—96,962
1937—91,566
1936— 88,457

1935—87,403

1930—98,882

1920—92,245

1910—64,109

1900—43,699

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1932. Fully equipped for major surgery and obstetrics.
Good chance for nurse and husband. Will sell on
terms, or will give good discount for cash. Ill health
reason for selling. If interested, write Rowe Me-
morial Hospital, Stockbridge, Michigan, for full par-
ticulars.

Physicians' Service Laboratory

608 Kales Bldg. —
Northwest comer of
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Kahn and Kline Test
Blood Count

Complete Blood Chemistry
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Allergy Tests
Basal Metabolic Bate
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Darkheld Examination

All types of mailing containers supplied.
Reports by mail, phone and telegraph.

Write for further information and prices.

308

Jour. M.S.M.S.

^ Woman’s Auxiliary -K

Only a few more weeks and the members of the
[Woman’s Auxiliary of the American Medical Associa-
Ition will be arriving in Cleveland for their annual con-
ivention, Jtme 2-6. Have you made your reservations?

I If not, send your request, at once, to Dr. Edward F.
[Kieger, Chairman of Committee on Hotels and Hous-
ing, 1604 Terminal Tower Building, Cleveland.

Bay County

The Woman’s Auxiliary to the Bay County Medical
Society met at the home of Mrs. D, J. Mosier on Feb.
12, for a buffet dinner at 6 :30, with twenty-one present.

Mrs. W. R. Ballard presided at the business meeting
which followed, and appointed Mrs. P. R. Urmston,
Mrs. E. S. Huckins and Mrs. R. C. Perkins on the
nominating committee to present a new slate of officers
at the next meeting.

The members decided to designate Tuesday as the
day the medical auxiliary would work at the Red
Cross rooms.

Miss Helen Hudson, general secretary of the Y.W.-
C.A., addressed the group on the subject, ‘Interna-
tional Trade Routes.”

Mrs. J. Norris Asline

Ingham County

The Auxiliary held its January meeting at the
home of Mrs. John Albers in East Lansing. The date
fell upon Inaugural Day, and the social chairman,
Mrs. Harold Miller, in cooperation with the hostess.

had arranged a most beautiful display of flowers and
lighted tapers in the patriotic colors of red, white
and blue.

The program chairman, Mrs. Robert Breakey, pre-
sented Mrs. Hugh Wilson of Ann Arbor as the
speaker for the afternoon. Mrs. Wilson won the
Avery Hoopwood award at the University of Michi-
gan several years ago and since that has published
many stories and plays in various papers and maga-
zines. We listened to a most interesting talk on her
career. Mrs. Harold Wiley, our president, selected
Mrs. L. G. Christian and Mrs. C. F. DeVries to aid
Mrs. E. I. Carr on the important legislative commit-
tee. The auxiliary voted to invite the Dental Auxiliary
to tea for next month. He hope this will be the be-
ginning of a friendship which will be of great mutual
value to both groups. The tea was held at the Sparrow
Hospital Nurses Home on February 17.

The Ingham County Auxiliary gave a tea in Feb-
ruary for the members of the Auxiliary to the County
Dental Society and the large attendance at this com-
bined meeting was most gratifying. We hope this will
establish a precedent for more meetings and deeper
friendly relations between the two groups.

Dr. Harold A. Miller, chairman of the Legislative
Committee for the State Medical Society, discussed
some of the many bills - to come up in the legislature
and explained the way bills go in for passage. It was
a timely discussion and an interesting question hour fol-
lowed. We had a friendly social hour following the
meeting and a lovely tea was served by Mrs. H. A.
Miller, Mrs. Robert Breakey and assistants.

Margaret S. Davenport

MICH.

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April, 1941

309

WOMAN’S AUXILIARY

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Jackson County

The February meeting of the Woman’s Auxiliary
to the Jackson County Medical Society was held at
the home of Mrs. Harold Hurley. Forty-one mem-
bers were present.

It was voted to accept the invitation of the Jackson
Woman’s Club to attend the lecture of Henry C. Wolf,
foreign correspondent, author, and lecturer, March 18.

The program was in charge of Mrs. George Hardie
who introduced Mrs. George Baker of Parma. Mrs.
Baker reviewed Evelyn Eaton’s “Quietly My Captain
Waits.”

The members were delighted with Mrs. Bakers in-
terpretation of the story.

Kalamazoo County

The January meeting of the Kalamazoo Auxiliary
was held at the home of Mrs. William E. Shackleton,
January 21. Mrs. Martin Patmos and Mrs. Katherine
Armstrong were the assisting hostesses.

A cooperative dinner was enjoyed by the thirty
members and guests present. The latter were wives of
the Medical Staff from Fort Custer.

Mrs. Kenneth Crawford, president, conducted the
business meeting. A report was made on the recent
purchase, by the auxiliary, of a wheel chair, which
is to be placed in the Loan Closet at the Health
Service in the City Hall. This chair is to be available
to anyone in the community in need of it.

Mrs. Walter den Bleyker, public relations chairman,
presented the program for the evening. Her subject
was “Socialized Medicine.”

310

The Auxiliary to the Kalamazoo Academy of Medi-
cine held a cooperative dinner Tuesday, February the
eighteenth, at the home of Mrs. W. Bartlett Crane,
South Rose Street. Mrs. Ralph Shook and Mrs. John
Littig assisted the hostess. A most enjoyable evening
was spent by the thirty-five members present.

Following the business meeting the remainder of the
evening was spent inJfonnally.

Frances Rigterink

Kent County

The January meeting of the Kent County Woman’s
Auxiliary was held in the Grand Rapids Public Mu-
seum.

After the luncheon served by teams led by Mrs.
Jerome Webber and Mrs. Harold Damstra the group
was addressed by Dr. Pearl L. Kendrick on “Contribu-
tions of the Public Health Laboratory to the Com-
munity.” Dr. Kendrick is Director of Western Michi-
gan Division of the Michigan Department of Health
Laboratories and is internationally known for her
fine work on pertussis vaccine.

A business session led by the president, Mrs. Guy
DeBoer, closed the meeting.

The February meeting of the Woman’s Auxiliary to
the Kent County Medical Society was held Wednesday
afternoon, the twelfth, in the auditorium of the Public
Museum. Mrs. J. E. Meengs presided at the business
meeting, after which Mrs. James A. Work, Jr. of

Jour. M.S.M.S.

WOMAN’S AUXILIARY

Elkhart, Indiana, presented a paper on “Dr. Albert
Schweitzer.”

A recording of Bach’s “Prelude to the Fugue in E
Minor” played by Schweitzer was given as an appro-
priate conclusion to Mrs. Work’s sketch.

Mrs. L. Paul Ralph and Mrs. George L. Riley and
their committees served tea after the program.

PE.A.RL GaIKEMA

Monroe County

On the afternoon of January 21, 1941, the Auxiliary
and guests met for luncheon at the Monroe Golf and
Country club. There were eighty-three in attendance.

Miss Margaret Slater, Sergeant Policewoman of the
Toledo, Ohio, Police Department, spoke on “Woman’s
Part in the Prevention of Crime.” She was presented
by Mrs. Robert J. Williams, President, who also pre-
sented two special guests, Mrs. Roger V. Walker,
president, and Mrs. A. O. Brown, secretary of the
State Auxiliary.

The Auxiliary met January 28 for an afternoon
meeting at the home of Mrs. Edgar C. Long. There
were twelve in attendance and after a short business
meeting tea was served by the hostess and the group
sewed for the Red Cross.

Genevieve L. Reisig,
Press Chairman.

Washtenaw County

The Woman’s Auxiliary of the Washtenaw County
Medical Society held its regular meeting in the Alich-
igan Union on Tuesday, December 10.

Airs. Alathew Soller, Public Health Nurse, spoke on
the Health Program in the public schools of Ann
Arbor. Airs. Robert Graham gave a number of book
reviews on popular medical books.

The members of the committee on British War
Relief were on hand to receive donations of blankets
and warm clothing to be sent to England.

The members also responded generously to a call
for food donations, to be placed in Yuletide baskets
for the needy.

The Woman’s Auxiliary of the Washtenaw County
Aledical Society enjoyed a potluck dinner meeting
Tuesday, January 14, at the home of Mrs. Harry A.
Towsley. After the routine busifiess meeting the mem-
bers played games and enjoyed a social hour.

The Auxiliary, with Airs. Dean Alyers as chair-
man, is collecting surgical instruments from meip-
bers of the profession to be sent to Great Britain.

Tlie February meeting was a joint meeting with the
husbands as guests at the Alichigan League.

Wayne County

The Woman’s Auxiliary to the W.C.AI.S. held its
December meeting on Friday the 13th at the So-
ciety’s headquarters.

The business meeting was followed by an address by
Colonel H. W. Aliller of the Engineering Department
of the University of Alichigan, who spoke on “The
Causes and Progress of the Present War.”

Colonel Aliller analyzed the present conflict in re-
spect to the racial characteristics of the warring na-
tions, their social and economic problems, and the
great wars of the past.

On Saturday, December 21, the children of mem-
bers of the Wayne County Aledical Society were guests
at a Christmas party at the Society’s clubrooms. Afore
than 150 little people were present to meet Santa,
who had brought gifts for each. A puppet show, a
children’s band concert, and a carol service were
followed by refreshments.

Gay little voices and merry laughter echoed through-

Thank you. Doctor.
I We look forward
to our visit here.

A friendly suggestion: Your '"littlest” patients aren’t the only

ones, Doctor, who enjoy CHEWING GUM

I I guess every one
\ likes to chew gum
/ it's so delicious*.

The enjoyment of delicious chew-
ing gum is a real American cus-
tom— probably because chewing
is such a basic, natural pleasure.

Enjoy chewing gum yourself.
See how the chewing helps relieve
tension by giving it a try during
your busy days.

Have some gum in your pocket
or bag and in the office. Your
patients — children and adults
— appreciate your friendliness
when you offer them some.
Try this for a month — you’ll
be pleased with the results.

National Association of Chewing Gum
Manufacturers, Staten Island, New York

April, 1941

Say you saw it in the Journal of the Michigan State Medical Society

311

THE FAMOUS MAYO SACRO-ILIAC BELT

at a New Low Price

The Belt That Has Traveled Around the World

Since the Mayo was desigrned some years ago, we have sent it to
nearly every country in the world — evidently the most efficient Belt
of its type on the market.

The Belt is made of heavy Orthopedic Web with a meparate abdom-
inal plate which allows for accurate adjustment and a suitable chamois
Sacral Pad which permits concentration on Sacrum. Belt should be
buckled tightly in front on each side, then all the pressure concen-
trated on pad by the lacings provided for that purpose. To fit, take
measurement around the hips three inches below the Iliac crests, or
directly over the trochanters.

Headquarters for
Trusses

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PRICE

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Sales Tax,
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out the rooms and were proof that the efforts of Mrs.
William L. Sherman, chairman of the Social Commit-
tee, were thoroughly appreciated.

The Woman’s Auxiliary to the Wayne County Medi-
cal Society held its regular monthly meeting on Friday,
February 14, at 2 :00 P. M.

Following the meeting Mrs. A. Ehiane Beam, Pro-
gram Chairman, presented Dr. Frederick S. Yonkman,
who spoke on “Experimental Contribution to Advance-
ment in Medicine.”

Mrs. Leo P. Rennell, Mrs. Louis J. Bailey, Mrs.
Richard C. Connelly, and Mrs. Edgar E. Martmer were
hostesses at the tea which concluded the program.

Margaret J. Wallace

The Mary E. Pogue School

For Exceptional Children

DOCTORS: You may continue to super-
vise the treatment and care of children
you place in our school. Catalogue on
request.

WHEATON, ILLINOIS

85 Geneva Road Telephone Wheaton 66

LETTER TO THE EDITOR

March 14, 1941.

Dr. Roy Herbert Holmes, Editor

Journal of the Michigan State Medical Society

Dear Dr. Holmes : Recently there has been estab-
lished in this library, with the approval of The Sur-
geon General of the Army, a microfilm copying service
and a weekly Current List of Medical Literature pre-
pared from the cards made for future issues of the In-
dex Catalogue. These two projects are conducted
under the auspices of a recently organized group of
Friends of the Army Medical Library.

The object of this undertaking is to place the re-
sources of this library at the disposal of those who
are engaged in the advancement of medical research,
irrespective of where they live or work.

Undoubtedly there are many readers of your jour-
nal who would be interested in learning of this service
and it would be highly appreciated if you could assist
us in making facts more widely known, through the
columns of your journal. As Librarian of the Army
Medical Library, I have a great interest in the work
the Friends of the Library are doing, and although I
take no part in this officially, I have left no stone un-
turned to aid them in their work.

Sincerely yours,

Harold W. Jones,

Colonel, MU., U. S. Army,

The Library.

Jour. M.S.M.S.

312

Say you saw it in the Journal of the Michigan State Medical Society

COUNTY AND PERSONAL ACTIVITIES

-K

130 Per Cent Club of 1341

Barry

Ingham

Luce

Manistee

Muskegon

Oceana

Ontonagon

Tuscola

The above county medical societies have cer-
tified the 1941 dues of 100 per cent of their mem-
bership. A number of other societies have cer-
tified all but a few of their 1940 members. As
soon as these few have paid their 1941 dues the
list of 100 per cent county societies will be much
larger.

Wfn. G. Gamble, M.D., Bay City, addressed the
Northern Michigan Medical Society at Cheboygan on
March 13 on the subject of “Shock.”

* * *

The Michigan Association of Industrial Physicians
and Surgeons will hold its 1941 annual meeting in De-
troit on April 16.

Frank H. Power, M.D., Field Consultant in Cancer
for the Michigan State Medical Society, addressed the
Athena Club at Algonac on Tuesday, March 4, on the
subject of “Cancer.”

* * *

The American Medical Golfing Association will hold
its 27th Annual Tournament on Monday, June 2, over
the Country Qub and Pepper Pike Courses, Cleveland,
Ohio. For detailed information and application blank,
write Bill Bums, 2020 Olds Tower, Lansing.

* * *

Louis J. Gariepy, M.D., Detroit, -was recently honored
with the presentation to him by the Staff of Alt. Carmel
Mercy Hospital of a beautiful plaque on which the
following inscription appears “Presented in recognition
of outstanding service.”

* *

The American Association of Industrial Physicians
& Surgeons will hold a postgraduate institute in Pitts-
burgh on Alay 5 to 8. The Institute will mark the
26th annual meeting of the Association and the second
annual meeting of the American Industrial Hygiene
Association.

^ ^ ^

Alpha Epsilon Delta, the national honorary pre-
medical fraternity, installed its thirty-second chapter
at the University of Detroit on Alarch 8, 1941, when
the Iota chapter of the Omega Beta Pi fraternity be-
came the Alichigan Alpha chapter with the induction
of twenty students and two faculty members.

Ukithkitis

(DUE TO NEISSERIA GONOPRHEAE)

SILVER PICRATE

k mdSt^atare wiH he seotup^reqaestj

JOHN WYEIH & SROTHER, INCORPORATED. PHILA.

ClPiiver Pkrate, Wyefh, has

0 convtnciRQ record of ellec>
f iveness as a local treof> ^
ment for acute anterior
urethritis caused by Nets>.
seria gonorrheae. U) An

^ ^oqueous solution (0.5 per-
cent) of silver picrafe or
water-soluble jelly (0,5 perv
^f) ore employed In the .
f treatments ,•

. L Knight. F., ai^ Sheian-
I ski. H. A., ’Treotmenl

of Acute Anterior
Urethritis with Silver
Picrote,” Am* J. Syph.
Gaks A Yen. 23, ^ 14

1 201(MaKh) 1939.:

- ■ A - . . ■

*Save» Piereite, is «i defin&e crynoi-
tn« sompouiMi of sSver cad p^e
acid. R is avoRolile in the form of
cfysifds and soluble trituradon for
Ihe prepondfoft of sofsliens^ sopi-
‘ posRories, water- soluUe |^y, oiid.
powder for vopiiioi insufUoHon.

April, 1941

Say you saw it in the Journal of the Michigan State Medical Society

313

COUNTY AND PERSONAL ACTIVITIES

Main Entrance

SAWYER SAMTDHIUM

White Oaks Farm

Marion, Ohio

For the treatment of
Nervous and Mental Diseases
and Associated Conditions

• Licensed for

The Treatment of Mental Diseases
by the Department of Public Welfare
Division of Mental Diseases
of the State of Ohio

Accredited by

The American College of Surgeons
Member of

The American Hospital Association
and

The Ohio Hospital Association

Housebook giving details, pictures,
and rates will be sent upon request.
Telephone 2140. Address,

SAWYER SAMTDRIUM

White Daks Farm

Marion, Ohio

George A. Zvndler, M.D., and Franklin O. Meister,
M.D., have joined the medical staff of the Battle Creek
Sanitarium. Dr. Zindler was associated with the Uni-
versity of Afichigan and Wayne University before en-
tering private practice in Detroit ; Dr. Meister has been
associated with the University of Wisconsin.

♦ ♦ *

“The Foundation Prize" of the American Association
of Obstetricians, Gynecologists and Abdominal Sur-
geons has been announced by James R. Bloss, M.D.,
Secretary, 418 11th Street, Himtington, W. Va. All
manuscripts must be in the hands of the Secretary
before June 1. The prize consists of $150.00. For rules
write to the Secretary.

* * ♦

Eloise Hospital, Psychiatric Division, announces its
second annual Post Graduate Qinic for General Prac-
titioners, Wednesday, April 23, 1941, from 8:30 A. M.
to 5 :00 P. M. All members of the profession are in-
vited. No fees.

♦ ♦ *

A one-day conference sometime in June on Student
Health Practice is being arranged for physicians and
others interested in this work. Address inquiries con-
cerning plans for the conference to Dr. Claire E.
Healey, University Health Service, University of Alichi-
gan, Ann Arbor, Michigan.

♦ * ♦

Wm. J. Burns, Executive Secretary of the M.S.AI.S.,
addressed the Highland Park Physicians Club in High-
land Park on March 6, on the subject of “The Trends
of Legislation.”

“Medical Legislation” was the subject of another
address by Mr. Burns before the Clinton County Medi-
cal Society on April 7 in St. Johns.

* * *

Carleton Dean, M.D., of Lansing has been appointed
Director of the Crippled Children Commission, effec-
tive April 1. Doctor Dean has been serving as Deputy
State Health Commissioner for the past year and half,
prior to which time he was director of a county health
unit in Northern Michigan. Doctor Dean comes to the
Crippled Children Commission with the best wishes
of the medical profession.

*

Michigam Medical Service and Alichigan Hospital
Service celebrated their First and Second Anniversaries
respectively at a banquet held on March 26 at the Hotel
Statler, Detroit. Father Alphonse Schwitalla, S. J.
Dean of the Medical School of the University of St.
Louis, and James A. H^unilton, Past President of the
American College of Hospital Administrators, were the
out-of-state guest speakers.

*

Basic Science Appeal Lost. — The chiropractors’ ap-
peal to the Michigan Supreme Court on the opinion
of Hon. Vincent M. Brennan, Judge of the Wayne
County Circuit Court in the case of Timpona vs. the
Basic Science Board testing the constitutionality of the
Basic Science Law, has been dropped. Therefore, the
opinion of Judge Brennan upholding the validity of
the Basic Science Law stands and the law’s constitu-
tionality is firmly established.

^ ^ ^

Captain L. A. Potter, Inspector for the Alichigan
Department of Health, has been busy investigating the
activities of irregular and tmlicensed practitioners.
Among those recently brought to court was a Charles
DeBoer a chiropractor of Lansing who has been prac-
ticing without a license. Niunerous other irregular
practitioners have removed signs indicating “doctor”
without qualification after investigation and warning
from Captain Potter.

314

Say you saw it in the Journal of the Michigan State Medical Society

Jour. AI.S.M.S.

COUNTY AND PERSONAL ACTIVITIES

The Parents’ Institute, Inc., of New York City, an-
nounces the introduction of TRUE COMICS which is
a magazine using the color appeal and other features
of popular comics, but depicting exciting events of
present and past history. It is the aim of the Parents’
Institute in introducing this educational magazine for
children to satisfy the demand for colored picture type
magazine but at the same time eliminate the lurid mag-
azines featuring fantastic excitement, in colored picture
form, portraying impossible, often grotesque characters.

OFFICIAL CALL

The American Medical Association has issued
the Official Call to the officers, fellows and mem-
bers for its 92nd annual session to be held in
Cleveland, Ohio, June 2 to 6, 1941. The head-
quarters hotel will be Hotel Statler, Qeveland.

Write Dr. Edward F. Kieger, 1604 Terminal
Tower, Cleveland, Ohio, TODAY for hotel reser-
vations.

The Annual Refresher Course given in Detroit will
be held on April 28 at Henry Ford Hospital ; April
29 at The Children’s Hospital ; and on April 30 at
Herman Kiefer Hospital. Among the lecturers in-
cluded on the three-day program are Drs. W. C. C. Cole,
P. J. Howard, Warren Wheeler, Don Barnes, J. A.
Johnston, J. P. Pratt, C. L. Mitchell, John Law, Ben-
jamin Carey, Zuelzer, T. B. Cooley, James Wilson, Lee
Vincent, Saul Rosenzweig, Loren W. Shaffer, Norman
C. Wetzel, Bruce Douglas, J. A. Kasper, E. E. Mart-
mer, Franklin Top and Donald Young.

* * * *

The American Academy of Physical Medicine will
hold i.ts nineteenth annual meeting and scientific ses-
sion on April 28-30, in New York City. Headquarters
will be in the Hotel Pennsylvania. Clinics will be held
at the Medical Center, New York Orthopaedic Hospital,
Post Graduate Hospital and the Skin and Cancer Hos-
pital. All members of the medical profession and those
of related interests are invited to attend. No' registra-
tion fee. Write Herman A. Osgood, M.D., 144 Com-
monwealth Avenue, Boston, Massachusetts, for detailed
information and program.

* * *

The Seventy-Sixth Annual Convention and Exhibition
of the Michigan State Medical Society will be held at
the Hotel Pantlind-Civic Auditorium, Grand Rapids,
September 17 to 19, 1941. A galaxy of eminent na-
tionally known physicians will bring you an intensive
three-day postgraduate program that you will not want
to miss. In addition, more than one hundred scientific
and technical exhibits will be displayed for your in-
formation and enjoyment. Plan now to come to Grand
Rapids next September. Write today for your hotel
reservations.

^ ^

Doctor, remember your particular friends, the ex-
hibitors, at your annual convention, when you have
need of equipment, appliances, medical supplies and
service. Here are ten more of the firms which helped
make the 1940 convention such a success :

Lea & Febiger, Philadelphia.

A. Kuhlman & Company, Detroit.

Jones Metabolism Equipment Company, Chicago.

The _G. A. Ingram Company, Detroit.

Horlick’s Malted Milk Corporation, Racine, Wisconsin.

Holland-Rantos Company, New York.

H. J. Heinz Company, Pittsburgh.

The J._ F. Hartz Company, Detroit.

Hanovia Chemical and Mfg. Company, Newark.

Hack Shoe Company, Detroit.

April, 1941

There’s no fee
for this
advice

In coses of real thirst, noth-
ing is more welcome to a
welcome guest than a high-
ball made with smooth, mel-
low Johnnie Walker . . .

★

IT'S SENSIBLE TO STICK WITH

Johnnie

f^LKER

BLENDED SCOTCH WHISKY

Red Label
8 years old

Black Label
12 years old
Both 86.8 proof

CANADA DRY GINGER ALE, INC., NEW YORK, N. Y.
SOLE IMPORTER

Say you saw it in the Journal of the Michigan State Medical Society

315

COUNTY AND PERSONAL ACTIVITIES

DeNIKE sanitarium, Inc.

Established 1893

EXCLUSIVELY for the TREATMENT

OF

ACUTE and CHRONIC ALCOHOLISM

Mild Neuropsychic Cases
Admitted

1571 East Jefferson Avenue
Cadillac 2670 Detroit

A. JAMES DeNIKE, M.D.

Medical Superintendent

316

Say you saw it in the Journal of

Doctors Recruiting. — Britain is beginning to feel a
shortage of doctors and is discussing with U. S. officials
some kind of appeal for volunteers from this country.
Since the U. S. fears a similar shortage later, a coun-
tersuggestion is being made in Washington. This is a
plan to encourage the several thousand refugee doc-
tors (mostly German and Austrian) now in the U. S.
to go to England. Many of these, for various technical
reasons, haven’t been able to obtain U. S. medical
licenses, but they would be welcomed by Britain. The
above ideas haven’t yet taken definite form, but specific
proposals are likely to be publicized before long. —
Newsweek, March 17, 1941.

* * *

Physical Examinations Ordered by Any Court, Board,
Etc. — A new law (Act 18 of 1941) has just been

placed on the statute books which requires the payment
of fees to persons ordered to take a physical examina-
tion by any court, board or commission, or other pub-
lic body or officer. The law is very brief and reads
as follows :

Whenever in any proceedings before any court, board or

commission, or other public body or officer, an order is made
by such court, board or commission, or other public body or
officer, requiring and commanding that a person shall submit to
a physical examination, the order shall also provide that the
attorney for such person may be present at such physical ex-
amination if the party to such examination desires that an
attorney representing him be present. The order shall also
recite and provide that the party to be examined shall, at least
3 days prior to the date set for said examination, be paid a
fee of $2.00 per diem for the day ordered for attendance, and
that such party also be paid a mileage fee at the rate of 10

cents per mile in going to the place of attendance, to be

estimated from the residence of such party. The court, board
or commission, or other public body or officer, may in its order
determine the fees and mileage to be paid, and when so fixed,
such determination shall be conclusive. A correct copy of
any written report rendered by the examining physician relative
to the condition of such person shall be delivered forthwith
to such person or his attorney.

♦ * *

The Radio Committee of the Michigan State Medical
Society has arranged broadcasts of talks on the fol-
lowing subjects over radio stations in Battle Creek,
Bay City, Detroit, Flint, Grand Rapids, Houghton,
Jackson, Kalamazoo, East Lansing, Muskegon, Mar-
quette and Port Huron : In December ; Diabetes, Sinus,
The Value of X-ray Examination in Accidents and
Emergency Cases, Colitis, Artificial Fever Therapy.

In January: Relationship of Dentistry and Medicine,
Scarlet Fever, Eyestrain in Mental and Physical De-
velopment, and Simple Facts about How We Hear.

In February : Premarital Examinations ; The Im-
portance of Prenatal Care; The Menopause; The
Value of Anesthesia in Surgery and Medicine.

In March: Can Cancer be Cured? Refrigeration
Treatment of Cancer, The Common Causes of Fatigue,
and Misconceptions About Heart Disease.

The members of the Radio Committee who arranged
for these worthwhile talks and the individual physicians
who delivered them have earned the sincere thanks of
the medical profession for a good piece of work.

* * *

DETROIT NEXT

Detroit was awarded the 1942 Conference. For the
first time in our history, the Detroit Society will be
host to the meeting of all the Chapters of the American
Society for the Hard of Hearing.

We are proud of the honor and privilege to entertain
and serve the members of this national body in our
beautiful city. It is our sincere hope that we shall be
able to stage as fine a Conference as the one just
closed in Los Angeles.

It is not too early to begin working now toward
that goal. We trust that our members will unite and
give us their earnest cooperation and help. — The
Rainbow.

Jour. M.S.M.S.

the Michigan State Medical Society

Acknowledgment of all books received will he made in this
column and this wdl be deemed by us as a full compensation
of those sending them. A selection will be made for review,
as expedient.

BIOLOGICAL ASPECTS OF INFECTIOUS DISEASE. By
F. M. Burnet, M.D., Assistant Director, Walter and Eliza
Hall Institute, Melbourne. New York: The MacMillan

Company. Cambridge, England: The University Press,

1940. Price: $3.75.

This Australian scientist discusses the various infec-
tious diseases from the standpoint of biology. In a
most interesting manner he portrays the universal sig-
nificance of bacteria and higher forms of plant and
animal life, including man. His words, “Infectious
disease is seen as a part of the balance of life where
existence of one form of life depends upon the exist-
ence of others.” To' every physician and member of
the allied professions it will provide interesting and
thought-provoking reading. It is recommended for
every physician.

I

' STRANGE MALADY. The Story of Allergy. By Warren T.
Vaughan, M.D. Line Drawings by John P. Tillery. New
York: Doubleday, Doran and Company, Inc., 1941. Price:
$3.00.

In this second book in the American Association for
the Advancement of Science Series, Vaughan has at-
tempted to simplify the knowledge and the theory of al-
lergic response. It would take an exceptionally well ed-
ucated layman to understand some of the chapters'but to
a physician who has not been able to keep up in the
study of this condition, this book will provide interest-
ing and informative reading. The use of cartoons in
describing the various reactions is especially commend-
able. The excellent standing of Warren Vaughan is
sufficient to warrant justification in recommending this
book.

ELECTROCARDIOGRAPHY IN PRACTICE. By Ashton
Graybiel, M.D., Instructor in Medicine, Course for Gradu-
ates, Harvard Medical School; Research Associate, Fatigue
Laboratory, Harvard University; Assistant in Medicine,
Massachusetts General Hospital; and Paul D. White, M.D.,
Lecturer in Medicine, Harvard Medical School; Physician,
Massachusetts General Hospital, in Charge of the Cardiac
Clinics and Laboratory. Philadelphia and London; W. B.
Saunders Company, 1941. Price; $6.00.

This volume is arranged as an atlas as well as a
study book on the interpretation of electrocardiograms.
The electrocardiograms have been carefully selected
and the scope is unusually complete. Every physician
who is interested in interpretation of electrocardio-
grams will be well repaid for adding this volume to his
library. The authors rank among the highest in this
field.

FOOD, TEET.H AND LARCENY. By Charles A. Levinson,
D.M.D., Author of “The Examining Dentist in Food
Hazard Cases.” New York: Greenberg, Publisher, 1941.

Price: $3.00.

The author has filled this book with case reports
and follow-ups on hundreds of true and false claims
of damage, to the teeth and mouth particularly, caused
by foreign .substance in foods. It is of interest to
all dentists and all physicians who are interested in the
medico-legal side of medicine. His pessimistic view
of the unscrupulousness of his professional colleagues
is‘ not pleasant but may be excused because of his long
association in investigating these types of swindles.

April, 1941

worth while laboratory exam~
inations; including —

Tissue Diagnosis

The Wassermann and Kahn Tests

Blood Chemistry

Bacteriology and Clinical Pathology

Basal Metabolism

Aschheim-Zondek Pregnancy Test

Intravenous Therapy with rest rooms for
Patients.

Electrocardiograms

Central Laboratory

Oliver W. Lohr, M.D., Director

537 Millard St.

Saginaw

Phone, Dial 2-3893

The pathologist in direction is recognized
by the Council on Medical Education
and Hospitals of the A. M. A.

LABORATORY APPARATUS

Coors Porcelain
Pyrex Glassware
R. & B. Calibrated Ware
Chemical Thermometers
Hydrometers
Sphygmomanometers

J. J. Baker & Co., C. P. Chemicals
Stains and Reagents
Standard Solutions

• BIQLOGI^AlS*

Serums Vaccines

Antitoxins Media

Bacterins Pollens

VVe are completely equipped and solicit
your inquiry for these lines as well as for
Pharmaceuticals, Chemicals and Supplies,
Surgical Instruments and Dressings.

RUPP & BOWMAN CO.

319 SUPERIOR ST., TOLE^DO, OHIO

317

Say you saw it in the Journal of the Michigan State Medical Society

SPRING PLEASURE

For your diabetic patients, call for de-
licious pastries (without sugar).

Try them, doctor.

Request samples.

CURDOLAC FOOD CO.

325 E. Broadway
Waukesha, Wisconsin

In Lansing

HOTEL OLDS

Fireproof

400 ROOMS

INGHAM COUNTY CLINIC

The Annual Clinic of the Ingham County Medical
Society will be held Thursday, May 1.

11:30 — Round table discussion by Dr. Tom Spies
of Birmingham, Alabama, and Dr. Harry
Newburgh of the University of Michigan —
“Management of Obesity.”

1 :30 — Dr. William Scott of Toronto, Ontario —
“Ante Partum Hemmorrhage.”

2:15 — Dr. John Lundy of the Mayo Clinic — “The
Choice of an Anesthetic.”

3:30 — Dr. John Scudder of New York — “Evaluation
of Shock and Its Treatment.”

4:15 — Dr. Owen H. Wangensteen of Minneapolis —
“Management of Abdominal Distension.”

5 :30 — Social Hour

6 :30 — Dinner

7 :30 — Dr. Tom Spies — “Avitaminosis and Nutrition.”

It is sincerely hoped that all members of the Michigan
State Medical Society and their friends and guests who
may find it possible to be present will take advantage of
the invitation of the Ingham County Medical Society
to attend this Clinic.

READING NOTICES

CHEMOTHERAPY IN GONORRHEA

The newer sulfonamides, sulfapyridine and sulfa-
thiazole, are rapidly revolutionizing the treatment of
all forms of gonococcic infections. This exact modus
operand! is not clearly understood but is assumed to
depend on an ill-defined, inherent action as an anti-
septic. The cure rates of both drugs, used in the male,
are about the same for both early and late cases, and
apparently reach 70 per cent or over (Bull. New
York Acad. Med., 17:39 and 64, 1941). Because of its
lower toxicity, sulfathiazole appears to be rapidly sup-
planting sulfapyridine in clinical usage. The sulfona-
mides are marketed by Eli Lilly and Company in a
wide variety of dosage forms.

HIS FIRST CEREAL FEEDING

The baby’s first solid food always excites the par-
ent’s interest. Will he cry? Will he spit it up? Will
he try to swallow the spoon? Far more important than
the child’s “cute” reactions is the fact that figuratively
and physiologically, the little fellow is just beginning
to eat like a man.

Many a parent, with limited knowledge of nutrition,
attempts to do the baby’s tasting for him. Partial to
sweets, the mother sweetens her child’s cereal. Dis-
liking cod liver oil, she wrinkles her nose and sighs :
“Poor child, to have to take such awful stuff!” The
child is quick to learn by example, and soon may be-
come poor indeed — in nutrition, as well as in mental
habits and psychological adjustment.

Appreciating the importance and difficulties of the
physician’s problem in establishing and maintaining good
eating habits. Mead Johnson & Company continue to
supply Pablum in its natural form. No sugar is added.
There is no corresponding dilution of the present pro-
tein, mineral and vitamin content of Pablum. Is this
not worth while?

NEW COLOR HLM ON
VITAMIN B COMPLEX AVAILABLE

The apparently high incidence of sub-clinical de-
ficiency states associated with the lack of the vitamin
B complex and the difficulty of recognizing and diag-
nosing such conditions make the announcement of a
new motion picture on the vitamin B complex one of
special interest. The title of the new film is “The
Vitamin B Complex” ; it is entirely in 16 mm. Koda-
chrome. A sound as well as a silent version is avail-
able to medical societies and medical schools.

The film is based largely on clinical material from
the Nutrition Clinic, Hillman Hospital, Birmingham,
Ala. The cases selected for the most part were not
so much those exhibiting the classical syndromes, but
rather were of the mild type frequently involving mixed
deficiency states and less endemic in character.

The film, “The Vitamin B Complex,” was produced
under the supervision of the scientific and medical
staffs of E. R. Squibb & Sons, and was reviewed be-
fore release by authorities of international repute in
the field of medicine and nutrition. There is no ad-
vertising in the film which is offered solely as a
conservative review of the present status of the sub-
ject. Inquiries with reference to the loan of the
film may be addressed to E. R. Squibb & Sons, Pro-
fessional Service Department, 745 Fifth Avenue, New
York, N. Y.

318

Say you saw it in the Journal of the Michigan State Medical Society

Jour. M.S.M.S.

ORETON-M

in tablets, is the new, orally

effective androgen producing full male hormone effects by mouth — valuable
as the supplementary or complete treatment of male sex hormone deficiencies.

ORETON Ampules are standard for male hormone therapy by injection, furnishing
intense, prolonged activity for all androgen indications: hypogonadism, the male
climacteric, impotence with androgenic deficiency, prostatism, control of functional
uterine bleeding, suppression of lacta-
tion, after-pains and breast engorgement.

ORETON

convenient, potent mode of admlhistratlon. In tubes and in single-dose Toplkators:

ORitOH-r* FOR mmmAll KORMONI ; ORITOH,^ THF PRORIOHATE; ORiTON-M,« THF mTHYL COMPOUND

- V ' ' ^ ' :,*Trade-Marks Reg. U. S. Pot. OflF.

CHERING CORPORATION • BLOOMFIELD « NEW JERSEY

May, 1941 331

Say you saw it in the Journal of the Michigan State Medical Society

>f HALF A CENTURY AGO >f

The Twenty-sixth Annual Meeting of the Michigan
State Medical Society was held a.t Saginaw, June 11
and 12, 1891.

The President, Lyman W. Bliss of Saginaw, gave
his annual address entitled, “The Dignity of the Pro-
fession.” He said :

“When we contemplate the marvelously constructed
house, in which for a few brief years dwells the im-
mortal soul of man, we are lost in wonder and awed
into silence at the stupendous hand-work of Almighty
God. No glowing language, no descriptive eulogy by
man, nor the thrilling measures of the poet’s verse can
paint the wonders of our human frame.” * * *

* * * “The physician is the guardian of this vast lab-
oratory of nature, and in order to show the great
responsibility that lies upon him, let us for a moment
consider some of his duties. The paramount object
of every practitioner should be to heal the sick, bind
up the wounded, and care for the distressed in the
most scientific, honorable, and gentlemanly manner.
This being the case, an intelligent profession is de-
manded ; demanded for a two-fold reason : first, be-
cause of the importance of the office of the practition-
er, his duty toward those placed within his trust, and
also because of the advanced age in which we live.
The days of log cabins, teams, spinning wheels,
hand looms, tallow candles and quack doctors are
ended. We are warranted in the belief that the
America of fifty years ago is just as much the America
of today, as the America of today will be the
America of fifty years hence. We are living in times
of mighty advancement, and the ragged, shoeless,
hatless boy of the street has opportunity to learn more
in a single year than did his forefathers in ten. In
ages gone by, the modern means of securing knowl-
edge was not placed within the reach of the common
people, but today our homes are filled with magazines,
newspapers, models of taste and labor and the knowl-
edge of art. These advantages increase our opportu-
nities and add to our responsibilities. The time was,
in some of our southwestern states, when a prac-
titioner’s complete equipment consisted of a box of
quinine, a keg of whiskey, a mustang pony and two
revolvers. Evidences of quackery practiced in years
gone by are still fresh in our memories. I remember
a circumstance which transpired in the presence of a
personal friend, in the State of Nebraska in 1880,
during the malarial season. A western doctor was
called to visit a family sick of fever and ague. After
the usual salutation and examination of their cases,
he said : “Some of you are seriously ill ; your chances

for recovery are certainly very slender, unless prompt
action and extreme measures are resorted to. You
will at once get some fish-worms, boil them in new
milk and then give’ the liquid to the sick members
of the family once every hour. If this treatment fails,

I know of no other th^t will restore health under
the circumstances.” Such transactions were numerous
and of vital injury to all honest, intelligent, and hon-
orable gentlemen connected with the practice of medi-
cine; but we rejoice that their days are numbered and
that pure dignity and ignorance never go hand in hand.
The people of today are a reading, intelligent and
observing people and will not be imposed ujpon. The
dignity of the jirofession is largely dependent upon
the gentlemanly conduct of the practitioner; haughti- .
ness or arrogance are sometimes mistaken for dignity,
but they are^ vasjly different True ' dignity, in any

?32

profession, is gentlemanly, kind, charitable, and never
fails to receive a just reward.

“The dignity of the profession is sometimes injured
by young and ambitious physicians, who are so anxious
to succeed that they frequently forget the obligations
of the practitioner to those engaged in the same pro-
fession. Everyone contemplating the practice of medi-
cine should remember that success cannot be secured
in a single day or year, and that the only .sure road
to a successful life is the way which leads us through
the fields of honesty and fair dealing one with another.
While we rejoice in the vigor of manhood, and love
to see every young man energetic and aspiring, we
should at all times remember that our obligations to
others should never be disregarded. On the other hand
a lack of self-confidence or desire to win has a damag-
ing influence and should always be avoided.” * ♦ *

* * * “'We cannot acquire success in any profession
or business in a day or even in a year. I, as a marks-
man, may make a marvelous shot, and it is the wonder
of the community and conversation of all. A young
man just commencing the practice of law makes a
great plea before a jury, and by this, it is generally
conceded that he won the case and secured the
verdict, yet this only gives him limited local reputa-
tion.

“Col. R. Finley Smiley, the distinguished Southern
orator, when addressing a class of law students, veryj
^ timely and very eloquently said : ‘Were a young law-

yer enabled to incorporate all the legal knowledge of
all the learned lawyers of heaven to the chariot of
eloquence and ride forth with Samson-like strength
and Demosthene’s oratory and hurl the fiery darts of
burning speech into the ears of the jury, until each
and every juror would, with weeping eyes and throb-
bing heart, fall speechless under the great pyrotech-
nical display of genius, he would then have only se-
cured a local reputation and one which, if not added
to, would wither and die before the frosts of ten>
winters had passed away.’

“A mechanic erects a costly house with wonderful
dispatch and great skill, and for a time he is the
subject of conversation in all the mechanical circles
of the neighborhood. Or a young minister delivers
a magnificent sernaon — strong in logic and practical
in its conclusions — and in a little time he is the admired
of all the admiring, yet this is not reputation, this
is not character, it is simply fleeting notoriety, which of
itself alone is almost valueless. A physician cures,
one remarkable case, in which he restores the almost
dead to life, and he also secures this notoriety for an
hour. But I, as a marksman, must be able to make
a winning shot whenever I raise my rifle. The young
lawyer will be expected to make subsequent efforts
of , equal strength, if not stronger than he made on
a prior occasion. He will have to make strong the
weak points of law and present the case to the jury,
successfully carrying it with him, before he will ever
secure the reputation and be recognized as a great
lawyer. The young mechanic will have to furnish evi-
dence of perseverance, skill, and success, time after
time, before a meritorious character is wholly formed.
Although the young minister may be petted and fon-
dled by some who would love to do him favor, he
must remember that he will be compelled to think .■
out for himself very many eloquent sayings and |
figures of speech and evince evidences of masterly ,
reason before he will ever be acknowledged as a fine
(Continued on Page 334)

JouiL M.S.M.S.

Research on a large scale
at Lederle Laboratories

i^derle is spending over $100,000 a year on
sulfonamide research and still more on other
pharmacological investigations. But the tradi-
tional eminence of Lederle is in biologicals and
the bulk of its research, employing many experi-
enced scholars and a generous-sized staff, is de-
voted to blazing new paths toward better and
still better antitoxins, anti-sera and vaccines.
There are over sixty virus diseases of man or
beast as yet unconquered, a new concept of the
nature of virus to be applied and new tools like
the air-borne centrifuges (60,000 r.p.m.!), the
Tiselius machines and the electron microscope,
all at work today for Lederle.

Fascinating fun for an eager staff in buildings
all their own on Lederle’s 200-acre serum farm!

Lederle Laboratories. Inc.

30 ROCKEFELLER PLAZA NEW YORK, N. Y.

May, 1941

Say you saw it in the Journal of the Michigan State Medical Society

333

logician or a great preacher. And the young doctor
has yet to watch over more than one desperate case
of sickness, and study the deranged system of more
than one poor dying patient before he can justly claim
title of a great physician.

“These cold facts sound harshly in the ears of thou-
sands of young men, who are dissatisfied with this
law and would like to have it changed. They think
it strange that the young lords of creation, endowed
with such wonderful faculties, accomplishments, and
wisdom, cannot at once receive the tribute and homage
paid to one whose whole life has been a life of study
and of toil. This is the primary cause of failure in
thousands of cases.

“Too many young men are willing to make a few
powerful efforts and then sit down in discouragement
and gloom and wait for fortune to crown them with
success. In view of the fact that there is no excel-
lence without great labor, it is the duty of everyone,
whether old or young, to achieve every possible victory
by personal efforts. Having spent many years in the
practice of medicine, my knowledge has been derived
by practical experience : and realizing the great neces-
sity of an intelligent profession, I entreat each and
every one of you, as fellow laborers, to use every
instrumentality for the furtherance of the profession
we have espoused, that good may be accomplished and
relief brought to every suffering one of the human
family that is placed within our care. And if our
breasts bear no jewels betokening the approval of an
earthly monarch, we know in our own hearts that we
have the approval of One greater than all kings and
potentates.

“Thanking you for the many tokens of regard and
honor shown me and wishing you all abundant success
in every laudable endeavor to advance the interest of
the profession, I close.”

COUNCIL AND COMMITTEE MEETINGS

1. Wednesday, April 9 — 6:30 p. m. — Industrial
Health Committee — Hotel Olds, Lansing.

2. Wednesday, April 16 — 7:30 p. m. — Representatives
of Groups Interested in Afflicted Child Legisla-
tion— Hotel Olds, Lansing.

3. Thursday, April 24 — 3:00 p. m. — Legislative Com-
mittee— Hotel Olds, Lansing.

4. Wednesday, April 4:00 p. m.— Child Welfare
Committee — WCMS Bldg., Detroit.

5. Wednesday, May 7 — 4:00 p. m. — Committee on
Distribution of Medical Care — Hotel Olds, Lans-
ing.

6. Thursday , May 8 — 3 :00 p. m. — Executive Commit-
tee of The Council — Hotel Olds, Lansing.

NEW COUNTY SOCIETY OITICERS
Lapeer

President — D. J. O’Brien, M. D., Lapeer
Vice President — K. W. Dick, M. D., Imlay City
Secretary-Treasurer — H. M. Best, M. D., Lapeer
Delegate — D. J. O’Brien, M. D., Lapeer
Alternate Delegate — H. M. Best, M. D., Lapeer.

Mason

President — W. S. Martin, M. D., Ludington
Secretary-Treasurer — C. A. Paukstis, M. D., Luding-
ton

St. Joseph

President — F. D. Dodrill, M. D., Three Rivers
Secretary-Treasurer — J, W. Rice, M. D., Sturgis
Delegate — R. A. Springer, M. D., Centerville
Alternate Delegate — J. W. Rice, M. D., Sturgis

COUNTY MEDICAL SOCIETY MEETINGS

Bay — Wednesday, March 26 — Bay City — Speaker : Rob-
ert Moehlig, M. D., Detroit — Subject: “Newer Ad-
vances in Endocrinology.”

Wednesday, April 9 — Bay City — Speaker : Gordon
Myers, M. D., Detroit — Subject: “Sulfathiazole.”
Berrien — Thursday, April 17 — Benton Harbor — Speak-
er: John M. Sheldon, M. D., Ann Arbor — Subject:
“Allergy.”

Calhoun — Tuesday, April 1 — Battle Creek — Speaker:
Robert S. Breakey, M. D., Lansing — Subject: “Gon-
ococcal Infection in the Female.”

Dickinson-Iron — Thursday, April 3 — Iron Mountain —
Speaker: Herbert Landes, M. D., Chicago — Subject:
“Hematuria as it Pertains to General Practice.”
Hillsdale—ThursddLy, March 27 — Hillsdale — Speaker : S.
Milton Goldhamer, M. D., Ann Arbor — Subject:
“Diseases of the Blood and Blood Organs.”

Ingham — Tuesday, April 15 — Lansing — Speaker: Fred-
erick H. Falls, M. D., Chicago — Subject: “Extra
Uterine Pregnancy.”

Jackson — Tuesday, April 15 — Jackson— Speaker : Robert

S. Breakey, M. D., Lansing — Subject: “Medical Re-
sponsibility in Venereal Disease Control.”

Kalamazoo — Tuesday, April 15 — Kalamazoo — Speaker:
Charles F. McKhann, M. D., Ann Arbor — Subject:
“Diarrhea and Vomiting in Infants.” Also colored .
motion pictures of contagious diseases presented by
Harry Towsley, M. D., Ann Arbor.

Keni — Tuesday, April 8— Grand Rapids — Speaker: S. .
Milton Goldhamer, M. D., Ann Arbor — Subject : “The •
Use of Liver and Iron in the Anemias.”

Muskegon — Friday, April 18 — Muskegon— Speaker :

Phillip Lewin, M. D., Chicago — Subject: “Common i
Disorders of the Foot and Ankle.”

Wednesday, April 2— Rotunda Inn— Speaker:
Arthur C. Curtis, M. D., Ann Arbor — Subject : “Re-
cent Advances in Chemotherapy.”

St. C/mV— Tuesday, March 25 — Port Huron— Speakers :
W. L. Brosius, M. D. and F. H. Topp, M. D. of De-
troit, conducted a clinical pathological conference.
Tuesday, April 8 — Port Huron — Business meeting.
Shiawassee — Thursday, April 17 — Owosso — Regular

meeting.

Washtenazv — Tuesday, April 8 — Ann Arbor — Speaker:
John A4. Sheldon, M. D., Ann Arbor — Subject: “Al-
lergy in General Practice.”

Wayne — Monday, Alay 5 — General Aleeting, joint ses-
sion with the Woman’s Auxiliary Alay 12 — Medical
Section Meeting. Speaker : Bernard I. Comroe, M.
D., Philadelphia — Subject : “Arthritis.”

May 19 — Annual Meeting. Election of Officers.

JJ’est Side — PlVayne County) — Wednesday, April 16 —
Speakers : Samuel J. Levin, M. D., Detroit on “Eczema
and Fungus Allergy”; Frank L. Ryerson, AI. D.. De-
troit on “Common Diseases of the Optic Fundi” and
presentation of talking motion picture entitled “The
Pre-school Child.”

Physicians' Service Laboratory

608 Kales Bldg. — 76 W. Adams Ave.
Northwest corner of

Detroit, Michigan

Kahn and Kline Test
Blood Count

Complete Blood Chemistry
Tissue Examination
Allergy Tests
Basal Metabolic Rate
A>nogenous Vaccines

Grand Circus Park

CAdillac 7940

Complete Urine Examina-
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Ascheim-Zonde

(Pregnancy)

Smear Examination
Darkfield Examination

All types of mailing containers supplied.
Reports by mail, phone and telegraph.

Write for further information and prices.

334

Say you saiv it in the Journal of the Michigan State Medical Society

Jour. M.S.M.S.

TKe journal

of the Michigan State Medical Society

Issued Monthly Under the Direction of the Council
Volume 40 May, 1941 Number 5

The Changing Pictnre
of Diahetes""

By Reginald Fitz, M.D.
Boston, Massachusetts

Reginald Fitz, M.D.

Lecturer on the History of Medicine,
Harvard Medical School; Member
Council on Medical Education and Hos-
pitals, American Medical Association;
Member Board of Regents, American
College of Physicians ; Member Ameri-
can Board of Internal Medicine ; Con-
sulting Physician, Peter Bent Brigham
Hospital, Boston.

■ In the preface to the first edition of “Treat-
ment of Diabetes Mellitus,” Dr. Joslin^ re-
marks, “I have sought to take advantage of what
many friends both in Germany and in Amer-
ica have taught me. Professors Naunyn, von
Noorden, Friederich von Muller, Magnus-Levy,
and Falta, all have helped me with my cases.”

A Fundamental Text

It so happened that not long ago in the Har-
vard Medical School Library I came across a
copy of “Der Diabetes Melitus”f by Naunyn. It
was first published in book form in 1906 and this
particular copy belonged to my father. Evidently
he had treasured it and like Dr. Joslin felt that
he, too, had been signally helped in the manage-

*From the Robert Dawson Evans Memorial for Clinical Re-
search and Preventive Medicine, Massachusetts Memorial Hos-
pitals, Boston. Presented at the annual meeting of the Michigan
State Medical Society, Detroit, Michigan, September 20, 1940.

tDr. Joslin has been kind enough to review this paper for
me. He tells me that Naunyn’s opinion regarding the correct
spelling of Diabetes Mellitus should be Inserted. Naunyn says,
“Few people except myself write of Diabetes Melitus. It is
customary, however, at least outside of England, to use the
word melituria and thus make of it a Greek derivative. To
me it seems sensible for the sake of uniformity and simplicity
to apply the same reasoning to the correct si>elling of Diabetes
Melitus, spelling the adjective melitus with one 1. This I ' do,
though I have few followers.”

May, 1941

ment of his cases by Professor Naunyn’s in-
fluence.

Naunyn’s book® makes interesting reading. It
is a scholarly piece of work, virile, imaginative,

I'" li. NAUNV.N

zwKn>s I ai nacL

. Kl kVjJi AI K TAFf C\ IM> o AKKIIJil .NGKN IM TK\fK„

WIEN, lUlH*..

AI.FliED HUI^DEK.

K II. A. UOF-

W.fCHIlA51lLiat KAlStJlUCHKX ASANKMiE t»U: WtSikXAiAIAfTE.X,

Fig. 1. Title page of Naunyn’s book, still one
of the most important texts on diabetes.

and well put together. It contains certain ideas
of fundamental importance : notably, the idea of
the unity of diabetes and that all diabetics are
linked together by a common bond — the inher-
itance of a diabetic tendency. Naunyn devotes
many pages to a discussion of the pathologic
physiology of diabetes, to the different glyco-
surias, to the clinical picture of diabetes, to the
classification of diabetes into acute and chronic
groups or into mild and severe cases, and he has
something to say about treatment — a hundred or

345

CHANGING PICTURE OF DIABETES— FITZ

TABLE I. COMPARISON OF AGE AT DEATH FROM DIABETES AND OF SEX DISTRIBUTION

OF FATAL CASES
In 1861-1870 and 1929-1938

Diabetic Deaths in England and Wales
1861-1870 (Dickinson)

Diabetic Deaths in Massachusetts
1929-1938 (Lombard)

Males

Total per 1,000

Females
Total per 1,000

Males

To'al per 1,000

Females
Total per 1,000

0- 9

103

24

85

38

0- 9

27

6

32

4

10-19

334

78

218

98

10-19

57

13

54

7

20-34

873

204

509

229

20-29

71

16

86

10

35-44

653

153

384

173

30-39

113

26

109

13

45-54

746

175

352

1.58

40-49

271

63

420

51

55-64

817

191

377

169

50-59

784

182

1,4.59

178

65-74

594

139

236

106

60-69

1,429

332

3,042

.371

75-84

146

34

55

25

70-79

1,231

285

2,.383

291

85-94

7

2

7

3 ‘

80-89

.308

71

590

72

90 +

18

4

27

3

Total

4,273

2,223

Total

4,309

8,202

%

66

34

%

34

66

so pages in contrast to nearly four hundred
pages devoted to other topics.

Naunyn knew a great deal about diabetes. He
was a voracious reader and so keen a student of
literature that even now if one wishes quickly to
find reference to anything bizarre in diabetes
Naunyn will have it. Above all, he liked diabetes
and the variegated problems presented by the
disease.

As I read Naunyn’s book I realized more
vividly that ever what astonishing progress has
been made in the clinical management of dia-
betes since his day. This progress, too, has all
come about in the medical lifetime of many doc-
tors who still are active. In 1908, when Naunyn’s
book was newly published, I can well remember
as a medical student listening to lectures on
diabetes by Dr. Joslin who spent considerable
time in trying to drill into his pupil’s heads the
formulary differences between acetone, diacetic
acid, and beta-hydroxybutyric acid. This sort of
diabetic teaching then was characteristic of the
times. Much more was known of the theory of
diabetes than of its practical therapy.

As I went through each chapter of “Der Dia-
betes Melitus” I kept thinking how interested
Naunyn would be in all the changes that have

346

come about since he wrote ; in the introduction
of convenient micro-methods for blood sugar de-
terminations, for instance, or in Van Slyke’s ma-
chine by which the true degree of acidosis can
be measured quickly, or in modern dietetics, or,
above all, in insulin and zinc protamine insulin
which have changed so completely the life history
of the average case.

It occurred to me that it might be inter-
esting to contrast diabetes as Naunyn saw it
with diabetes as any doctor in 1940 sees it in
order to bring out, as graphically as I could,
how much we owe to him, how fortunate we
are in having present-day weapons at our dis-
posal, what a dent these weapons have made
in the face of a time-honored illness like dia-
betes, and how, in spite of this, what a baffling
disease in many ways diabetes continues to
remain.

I mentioned my plan to Dr. Joslin and asked
him whether he thought the essential character of
diabetes had4:hanged at all. He said, no; he felt
that diabetes was the same old disease, funda-
mentally as it always had been and only seeming-
ly modified by modern treatment. This seeming

Jour. M.S.M.S.

CHANGING PICTURE OF DIABETES— FITZ

modification in the course of the disease, how-
ever, and all the new clinical problems which
have arisen by its seeming modification are im-
pressive enough to suit anyone. Certainly, our
modern diabetic problems would be of great in-
terest to Professor Naunyn.

were reported 6,496 fatal cases, and only about
a third of these implicated the female sex.

If one compares Dickinson’s figures with fig-
ures of fatal cases assembled from modern sta-
tistics such as in Massachusetts^ between 1929
and 1938, it is evident that a very striking change

Age in. years

Fig. 2. A comparison of the age per thousand of fatal diabetic cases in England
1861-1870 and in Massachusetts 1929-1938. The solid line represents the earlier series.
The age at which diabetics die has changed remarkably.

Comparative Study

Naunyn built his book almost entirely on a
wide knowledge of diabetic literature superim-
posed on the experience he had gained from
carefully studying 131 cases in his own private
practice. During the period of three years be-
tween 1936 and 1939 my staff and I had oppor-
tunity to study, in the Robert Dawson Evans
Memorial, as intensively as we wished, a group
of 114 cases. It is interesting to contrast diabetes
as we saw it recently in a modern institution with
diabetes as Naunyn saw it before 1906.

Influence of sex. — Naunyn, of course, believed
that diabetes was predominantly a disease of the
male sex. His reasons for believing this were
twofold; because in his practice he saw more
men than women with it, and because of accu-
mulated statistics. No doubt his own experience
led him to place considerable emphasis on the
figures assembled by Dickinson from the Reg-
istrar General’s reports in England and Wales.
During the decade between 1861 and 1870 there

has occurred. Diabetes no longer is predominant-
ly a disease of men : rather it appears as a dis-
ease more likely to prove fatal to women.

Unfortunately, Dickinson’s figures are not tab-
ulated in exactly the same form as are the Massa-
chusetts figures. However, besides showing that
more women now die of diabetes than do men,
the table also points out pretty clearly another
great change. In Naunyn’s time young people
who developed diabetes were likely to die prompt-
ly, whereas now they do not. Therefore, Naunyn
was, by necessity, especially interested in the
acute form of diabetes in the relatively young and
was not much impressed by the geriatrical com-
plications of diabetes which are now so impor-
tant.

Climacteric. — Nor did he recognize another in-
teresting diabetic phenomenon. This is the sharp
rise in the severity of diabetes which occurs in
both sexes at about the time of the climacteric
and during the years following it. Naunyn says
that Lecorche claimed that the occurrence of

May, 1941

347

CHANGING PICTURE OF DIABETES— FITZ

severe diabetes in women at this particular time
was a significant happening. But Naunyn goes
on, “My own experience does not confirm this
observation nor do Dickinson’s figures bear it
out.” Thus, he failed to pay attention to a very
curious thing.

begins to increase very rapidly and increases for
the next thirty years of life, an excess mortality
from diabetes among women as compared with
men being characteristic of the diabetic situa-
tion everywhere.

Lecorche, perhaps, was more farsighted than

Age in Years

Fig. 3. The severity of diabetes shortly after the menopause as judged by fatal cases.
(From Massachusetts figures 1929-1938.)

As a matter of fact, modern statistics from a
variety of sources generally agree that diabetes
is seen more frequently in women than in men.
Those who agree with Dr. Joslin that diabetes is
the same old disease as ever, accept Boulduan’s^
explanation as to why its frequency in women
was overlooked. Nobody searched for it in
Naunyn’s time as we do nowadays. Life insur-
ance figures, for example, show that fifty or sixty
years ago the proportion of women applying for
insurance was small, whereas now more women
apply than do men. Doctors did not examine the
urine of their women patients routinely as they
do now. Patients did not know how to test their
own urines or samples from their families and
friends. There was greater self-consciousness in
mentioning such matters. Thus, the true fre-
quency of diabetes in women was overlooked.

No great emphasis since Lecorche wrote has
ever been placed on postmenopausal diabetes.
Even Dublin,^ who juggles diabetic figures with
as much agility as anyone, merely remarks that
around the menopause the female diabetic rate

348

subsequent observers. He thought he recognized
a connection between the incidence of diabetes
shortly after the menopause and this event.

If one does what Naunyn or Lecorche did not
have the knowledge to do, and links this coinci-
dence with Young’s work by which was produced
experimental diabetes in animals through in-
jections of anterior pituitary lobe extract, and
with what the modern endocrinologist tells us
of the hyperactivity of the anterior lobe at the
time of the menopause, one can easily construct
a very pretty theory logically to explain the fre-
quency of postmenopausal diabetes. Certainly,
this phase of the diabetic situation deserves more
careful study than it has so far received.

To return to a comparison between Naunyn’s
diabetic experience and what is seen today, the
first striking difference has been mentioned : the
difference in sex distribution. Of Naunyn’s 131
cases, only twenty-two were in women. Of the
114 Evans cases, only thirty-five were in men.

Influence of Age. — The second striking differ-

JouR. AI.S.M.S.

CHANGING PICTURE OF DIABETES— FITZ

ence is in the age spread of the material. Also,
as has been suggested, Naunyn saw mainly pa-
tients whom nowadays we would regard as young-
sters— not a single patient over seventy years of
age and mainly people in the forties. In the
Evans we had one patient more than eighty years

cide to what extent the steady increase in deaths
ascribed to diabetes in advanced ages represents
a true increase in incidence of the disease and
to what extent it is due to an increase in recog-
nition of diabetes with mention of it on death
certificates.

TABLE II. A COMPARISON OF THE AGE OF PATIENTS WITH DIABETES WHEN FIRST
SEEN IN A GROUP OF CASES BEFORE 1906 AND IN A GROUP OF CASES TODAY

Naunyn
(before 1906)

Evans Memorial
1936-1939

Age

Cases

Age

Cases

0-10

2

0-10

0

11-20

7

11-20

4

21-30

12

21-30

6

31-40

20

31-40

12

41-50

39

41-50

21

51-60

29

51-60

31

61-70

18

61-70

26

71-80

0

71-80

12

81-90

0

81-90

1

old, twelve patients over seventy, and our larg-
est group was in the fifties.

Stocks^ has published a stimulating paper on
this phase of the diabetic problem based largely,
as were Dickinson’s statistics, on figures from
the Registrar General’s office in England. In
brief, Stocks believes there is very good proof
since the introduction of insulin that there has
been an average lengthening of life of all dia-
betics amounting to three-and-a-half years. The
average advantage to the treated case, excluding
those not receiving the benefit of insulin, would,
of course, be considerably higher.

Increase in Incidence. — He makes a peculiar
observation, however, which is worth thinking
about. He says that the mortality attributable to
diabetes in Great Britain has continued to in-
crease since 1922, at ages over fifty-five, at a
greater rate than can be accounted for by the
postponement of death from the younger ages
by insulin; and that the increase in this form of
diabetic mortality has been proceeding at about
the same rate as during the decade preceding the
Great War. He grants that it is^ difficult to de-

One of the Evans patients, a man sixty-two years old,
is a case in point. He had syphilitic aortitis, con-
gestive heart failure, and lesions in the islands of
Langerhans entirely characteristic of diabetes. He gave
a history of polyuria and polydipsia. His fasting blood
sugar level was between 120 and 140 mgm. per cent.
Several urine samples were examined and found not to
contain surgar.

Naunyn, finding no sugar in the urine, being unfamil-
iar with the finer histologic changes in the diabetic
pancreas and without ready facilities for estimating
blood sugar concentration, in all probability would
have not included this case in his series. Modern
knowledge and the desire for more accurate vital sta-
tistics now make it seem reasonable to make the
diagnosis of diabetes in this instance. Increasing ac-
curacy is almost certain to be one continuing factor
in appearing to bring to light an increasing incidence of
the disease.

Naunyn regarded diabetes as a relatively acute
disease. As one reads his case reports one finds
again and again at the end of many, the melan-
choly note, ‘'Atemziige etwas ktirzer. Tracheal-
rasseln. Exitus im tiefsten coma.”

Duration. — He reports the duration of the dis-
ease, as he saw it in 141 cases selected from his

May, 1941

349

CHANGING PICTURE OF DIABETES— FITZ

TABLE III. THE USUAL DURATION OF DIABETES

BEFORE 1906

Duration of the Disease

Cases

Up to 1 year

42 (30%)

1 to 2 years

35 (25%)

2 to 3 years

23 (16%)

3 to 4 years

14 (10%)

4 to 5 years

5 (3%) ■

5 to 6 years

7 (5%)

6 to 8 years

6 (4%)

8 to 10 years

1 (1%)

10 to 12 years

6 (4%)

As long as 16 years

1 (1%)

Longer than 31 years

1 (1%)

Total

141

private practice and the clinic, as shown in Table
III.

The Evans experience is very different. We
were continually impressed with the large num-
ber of patients whom we saw with long-standing
diabetes. The duration of the disease up to the
time of entry to the hospital, in those who could
give an acceptable history regarding time of on-
set, is tabulated. Of these patients the majority
are still alive and going strong.

The record case in the Evans group is Mr. M. whom
I first saw in Dr. Joslin’s office about twenty-five years
ago. Actually, his diabetes was discovered thirty-one
years ago when he was twenty-six years old. Dr. Joslin
soon recognized that the diabetes was atypical for I
can remember that Dr. Joslin told Mr. M. never to
stay entirely sugar-free. Mr. M. has followed this ad-
vice. He now takes a little insulin each morning and
does not stay entirely sugar-free. Unfortunately, he has
developed angina pectoris ; but he is fifty-seven years
old, fairly well in spite of the handicap of diabetes
for so many years, and easily is able to carry on a
gainful occupation.

Naunyn would have been interested to know
that within the relatively short period of thirty-
five or forty years after his book was published
something could have taken place to make of
diabetes a relatively safe disease, to bring it about
that while in his day 80 per cent of the cases lived
for less than four years after they were recog-
nized, the time was soon to come when at least 60

per cent would live for a great deal longer period
than this. He would have been surprised, too,
at diabetes ever becoming so tractable that no
doctor would consider it at all unusual to see
patients who had withstood the disease happily '
for ten, fifteen or twenty years or more.

There are several reasons why long-stand-
ing cases are often encountered : better knowl-
edge of diabetic care, earlier diagnosis, good j
follow-up work in out-patient clinics but i
especially, of course, because of insulin. None |
of Naunyn’s cases could receive the benefit of |
this drug. Of the Evans cases, seventy-five |
(70 per cent) either were taking it regularly, |
had taken it before they came to the hospital, |
or were taught how to use it on arrival. Even |
the most casual injector and the patient least
likely to learn dietary discretion appeared to ]
obtain great benefit from insulin and, if ac- j
complishing nothing more, managed far to out- j
live what Naunyn would have regarded as *
a reasonable diabetic life expectancy.

Causes of Death

Diabetes, however, remains a threatening dis-
ease. Of Naunyn’s 131 cases, forty-nine were
followed to necropsy. In 1910, when I was a
Massachusetts General Hospital house pupil, we
admitted forty-two cases to the medical wards
during my term of service, and of these seven

TABLE IV. THE USUAL DURATION OF DIABETES

IN 1940

Duration of the Disease

Cases

Up to 1 year

11 (12%)

1 to 2 years

7 (7%)

2 to 3 years

10 (11%)

3 to 4 years

5 (5%)

4 to 5 years

8 (8%)

5 to 6 years

5 (5%)

6 to 8 years

11 (12%)

8 to 10 years

9 (10%)

10 to 12 years

8 (8%)

As long as 16 years

17 (18%)

20 years

2 (2%)

Longer than 30 years

1 (1%)

350

Jour. M.S.M.S.

CHANGING PICTURE OF DIABETES— FITZ

TABLE V. THE UNFORTUNATE COURSE OF VASCULAR HYPERTENSION IN DIABETES

Blood

Urine

Blood

Date

Weight

Pressure

Sugar

Albumin

Sediment

N.P.N.

Sugar

Remarks

1-17-34

136

190-100

s.p.t.

0

Negative

34

.14

4-17-34

131

5%

0

<<

.26

10 Units old Insulin.

Dieting carefully.

1-10-35

132

200-100

s.p.t.

0

.16

0-24-35

133

200-100

v.s.t.

0

41

.16

12-23-35

131

225-120

0

0

<1

.14

Shocked badly by recent

sudden death of daughter.

rare

8- 9-37

135

1%

0

granular

28

.26

Suddenly developed Bell’s

cast

Palsy.

11-19-37

135

240-120

1.7%

0

31

.30

Now has shifted to Zinc-Pro-

tamine Insulin. Says she is
sugar-free “most of the

rare

time.”

4^14-38

131

240-110

3.1%

0

red cell

35

.31

Likes Zinc-Protamine Insulin

but does not stay sugar-
free. Dose increased.

9-14r-38

134

230-120

t.

f.p.t.

Negative

37

.37

Feeling very well. Does not
stay sugar-free. Feels
“weak” if she takes more

4-22-39

Suddenly collapsed and died of what appeared chmcally to be cardiac infarction.

Insulin.

(17 per cent) died before much time had elapsed.
In those days, for a diabetic to enter a hospital
was likely to be dangerous. While the immediate
mortality of the treatment of diabetes in hospitals
now .has become negligible, yet diabetics do not
live indefinitely. It was somewhat disconcerting
to realize, as we followed up the Evans cases,
that of the 113 patients who were studied between
1936 and 1939, fifteen already are known to be
dead. Naunyn, however, saw a different cause of
death than did we. In his forty-nine necropsied
cases, fifteen (31 per cent) died in coma, sixteen
(33 per cent) had tuberculosis — at times, to be
sure, complicated by coma — and only nine (18
per cent) appeared to have significant vascular
disease. Of our fifteen fatalitits, one (7 per
cent) died in coma, and eleven (73 per cent)
died as the direct result of some vascular com-
plication. Certainly, vascular disease, instead of
coma or tuberculosis, has become the diabetic’s
bugbear. Whether one studies diabetes with the
pathologist or during life, as did Friedman,^ the
incidence in long-standing cases of a profound
degree of arterial degeneration with its compli-
cations is the most unmistakable finding.

Mrs. S. was first recognized to have diabetes in
1932, when she was forty-one years old. In 1934, she
weighed 136 pounds but had a blood pressure of 190/
100. She took small doses of insulin or protamine zinc

insulin regularly. In 1937, she developed a Bell’s Palsy
which cleared up slowly, and after this her diabetes
seemed less easily controlled. However, she appeared
to feel perfectly well. In 1939, she went downtown one
day, suddenly collapsed, and died shortly — apparently
of cardiac infarction. Could anything have been done
to prevent the development of her vascular disease
or to postpone the final accident?

Vascular disease in all its forms, with or
without hypertension, with or without gangrene,
with or without nephritis or cerebral apoplexy,
is seen so frequently that its prevention or the
mitigation of its course in the diabetic is highly
desirable. New knowledge about arteriosclerosis
is badly needed.

Diabetic Coma. — Naunyn would have consid-
ered it almost unthinkable to imagine that dia-
betic coma could become a relatively simple dia-
betic complication, easily amenable to treatment.
Yet, actually, insulin has made this possible.

The Evans case which I should have most enjoyed
demonstrating to him as typical of these times is Mrs.
C., a known diabetic of seven years’ standing, who twice
previously had been in severe acidosis. She had been
taking insulin regularly but abandoned it a week before
coming to the hospital, and when she arrived Naunyn
would have agreed that she presented, “Atemziige etwas
kiirz. Im tiefsten coma.” We were able to do quickly,
as a matter of course, things that Naunyn would have

May, 1941

351

CHANGING PICTURE OF DIABETES— FITZ

regarded as impossible ; the immediate estimation of
the blood sugar and CO2 levels, the administration of
large amounts of insulin, the continuous administra-
tion of fluids by vein and under the skin, and to give
her adequate, well-trained, skillful diabetic nursing
care.

Surgery. — Naunyn dreaded surgery in diabe-
tes. He knew the bad side of the picture and
remembered postoperative coma developing fre-
quently after chloroform, ether or local anesthet-
ics : so about all he had to say of diabetic surger}'

Fig. 4. Electrocardiographic tracings and chest radiograph in a fatal case of diabetes with hypertension a year before
death. The heart is slightly hypertrophied. The electrocardiogram shows left ventricular preponderance, abnormal ventric-
ular complexes, and absence of “r” in the fourth lead. Could the inforrcation derived from these findings have been
used rationally to delay the final outcome?

Even though the treatment of diabetic coma is
now fairly standardized, very simple, and the
mortality from coma is much less, atypical cases
still are encountered.

C. B., a man of sixty, was a known diabetic of twenty
years’ standing. Three weeks before entry to the
hospital he noticed that he was becoming weak, thirsty
and sleepy. Four days before entry he began to vomit
and he said that this had become an almost contin-
uous performance. On arrival the urine contained
sugar, acetone, no diacetic acid, a little albumin, and
rare hyaline and granular casts. He was treated as
though he were about to develop coma. After recovery
he was found to have as high as 52 points of hydro-
chloric acid in the gastric juice after an alcohol test
meal. Did he have diabetic acidosis masked by a
relative alkalosis that came from vomiting off hydro-
chloric acid, or did he have something entirely dif-
ferent?

was to avoid it if possible; if impossible, to pro-
tect the patient by pre-operative and postopera-
tive dietetic care as best one could, using lots of
sodium bicarborig^te as a prophylactic against the
acidosis which was well-nigh certain to develop.
I would have liked him to have seen Mrs. A.

Mrs. A., sixty-three years old, developed diabetes
nearly twenty years ago. She has had a cholecystec-
tomy, an operation for hemorrhoids, the repair of a
ventral hernia, and an emergency operation to unravel
a strangulated femoral hernia during her diabetic life-
time, all under ether anesthesia. She now goes serenely
about her business, a regular taker of insulin, and with
vascular hypertension.

Certainly, diabetic surgery is now very differ-
ent than it was in Naunyn’s day. Diabetics with-
stand surgery about as well as anyone.

352

Jour. M.S.M.S.

CHANGING PICTURE OF DIABETES— FITZ

Inheritmice Factors. — Xaunyn believed that
liabetes was due to an inherited liability to the
iisease which was brought to life by factors the
ixact nature of which were not clearly defined.
From the point of view of knowing exactly what

were compared with the family histories of
ninety-six diabetics. Adequate histories in the
remainder of the diabetic group were not satis-
factorily obtainable because of language difficul-
ties.

TABLE VI. THE MODERN TREATMENT OF DIABETIC COMA

Date

Time

Blood CO 2
vols.

%

Blood Sugar
mgm.

/C

July 19

5 p.m.

10

800 +

50 Units Insulin

6

50 Units Insulin

8:30

30 Units Insulin

30 Units Zinc-Protarnine

10

11.7

425

20 Units InsuUn

12

20 Units Insulin

July 20

2 a.m.

20 Units Insulin

4 a.m.

20 Units Insulin

6 a.m.

20 Units Insulin

7 a.m.

35

200

Patient received from 5 p.m. imtil 6 a.m. 1,000 c.c. of saline by vein and 2,000 c.c. sub-
cutaneously. She was conscious and comfortable. From then on it was plain saiHng,

TABLE VII. LABORATORY FINDINGS IN AN ATYPICAL
CASE OF DIABETIC ACIDOSIS

Date

Blood

N.P.N.

Sugar

CO 2

NaCl

mgm.

07

/o

mgm.

%

vols.

%

mgm.

%

April 21

75

400

57

443

22

71

364

433

24

50

266

68

26

39

172

28

36

168

486

May 1

35

154

493

11

30

158

63

593

causes diabetes, we are little further ahead than
we used to be. There is no doubt, however, that
the diabetic tendency runs through families and
that there is a relationship between diabetes and
obesity. For the sake of bringing out these
points, the family histories of 126 non-diabetic
cases, as taken routinely in the Evans Memorial,

This small group of cases ran true to form.
The diabetic familial tendency was much more
noticeable among the diabetics than among the
non-diabetic group.

Obesity. — The factor of obesity as a possible
precursor to diabetes was even more clearly
apparent.

TABLE VIII. A COMPARISON OF FAMILY HISTORIES
IN A GROUP OF UNSELECTED NON-DIABETIC
AND DIABETIC PATIENTS

126 Non-diabetic Patients

96 Diabetic Patients.

None had diabetic fathers
(0%)

4 had diabetic fathers
(4%)

6 had diabetic mothers
(5%)

6 had diabetic mothers
(6%)

1 had a diabetic brother
(1%)

4 had diabetic brothers
(4%)

6 had diabetic sisters (5%)

9 had diabetic sisters (9%)

1 had a diabetic child (1%)

3 had diabetic children (3%)

May, 1941

353

CHANGING PICTURE OF DIABETES— FITZ

New Problems

The fundamental differences, boiled down, be-
tween diabetes as Naunyn saw it and as it ap-
pears today are in the sex and age distribution
of the patients and in the duration of the disease.
The gravity of diabetic coma or of tuberculosis

a hard, irregular, inoperable cancer surrounding the
rectum. He died within seven months after we first saw
him.

Naunyn was a rare student of diabetes and
paved the way for modern treatment. Banting

Maximum Weight (lbs.)

Fig. 5. The factar of obesity as a precursor of diabetes. The dotted line represents the maximum weight of 126
unselected non-diabetic patients: the solid line the maximum weight of 114 diabetics. Persons at one time notably over-
weight were encountered among the diabetics with much greater frequency than among the non-diabetics.

as a complication of diabetes is much less. The
surgical aspects of diabetes are no longer hazar-
dous. Fatal diabetes no longer occurs regularly
in young people. Because diabetes and longevity
are now compatible, the modern doctor is faced
with a variety of new diabetic problems which
Naunyn did not foresee. Of these, by all odds
the most important is the management of vascu-
lar disease, and probably the next most impor-
tant is the early recognition of cancer.

Mr. W. was seventy-two years old when he entered
the Evans Memorial in January. Three years pre-
viously it was discovered that he had diabetes. He
came to the hospital because of a painful, swollen
foot, the result of cutting a toenail. The only un-
toward symptom of which he compla'ned while he was
in the hospital was of an attack of diarrhea lasting
for several days. Ordinarily, he said, his bowels were
constipated and to have diarrhea surprised him. The
stools did not contain fresh or occult blood. Rectal
examination revealed a symmetrically enlarged pros-
tate with nothing else. He remained under cover for
three weeks. Two months later he reentered, now with

and Best added insulin. The modern doctor must
learn to prescribe insulin wisely since the vast
majority of diabetics, even the mild cases, are
benefited by its use. He must also be guided by
Naunyn and study his cases as individuals as
carefully as did that wise old clinician.

Periodic Examination. — Because of insulin
diabetic patients will live to be observed for long
periods of time. If there is any field in internal
medicine where periodic health examinations are
important it is in the management of diabetes.
Diabetic patients must be reexamined again and
again ; to focus too much interest on diabetes — on
blood and urine sugar analyses alone — is now |
unsound. The complications of diabetes have i
become the important feature of the disease rath-
er than the disease itself. By recognizing com- ,
plications early — surgical complications, vascular
complications or the early stages of diseases like
cancer which may develop in the diabetic individ-

354

Jour. M.S.M.S.

URETHRAL DIVERTICULA— ARONSTAM

I

f| ual entirely independent of diabetes — steps may
il be taken to practice intelligent preventive medi-
i\ cine and thus to afford the diabetic as good if
:i not better a life expectancy than can be offered
j; his non-diabetic friend, less likely to submit to
: medical checking ever so regularly.

‘ The Specialist in Diabetes

i The physician who thinks of specializing in
! diabetes is tempted to become a medical menace.

I For diabetes is not a specialty. The doctor best
!f fitted to give diabetic patients most satisfactory
|l supervision will be like Naunyn: a broad-gauged
if clinician interested in all aspects of medicine, up-
I to-date in all fields, a keen student, a hard work-
i er, and regarding diabetes not as a narrow sub-
ject but as a disease presenting such variegated
problems as to include the whole scope of medi-
cine and surgery.

References

1. Bolduan, C. F. : Diabetes, an important public health prob-
lem. Am. Jour., Pub. Health, 28:21-26, (Jan.) 1938.

2. Dublin, L. I.: Recent trends in diabetes mortality. Mili-

' tary Surg., 17:57-75, (Aug.) 1935. ,

3. Friedman, G. : Cardiovascular status o£ diabetic patients

after the fourth decade of life. Arch. Int. Med., 55:371-394,
(March) 1935.

4. Joslin, E. P. : The Treatment of Diabetes Mellitus. Phila-
delphia: Lea and Febiger, 1916.

5. Lombard, H. L. : Personal communication from Massa-

chusetts State Department of Public Health, 1939.

6. Naunyn, B.: Der Diabetes Melitus. Wien: Alfred Holder,
1906.

7. Stocks, P. : The lengthening of life by modern therapy in
pernicious anemia and diabetes. Brit. Med. Jour., 1:1013-
1017, (May 18) 1935.

8. Young, F. G. : The anterior pituitary gland and diabetes

mellitus. New Eng. Jour. 'Med., 221:635-646, (Oct. 26)
1939,

Third Annual Fracture Day

The third annual Fracture Day program, sponsored
by the Flint Regional Fracture Committee and the
Genesee County Medical Society, will be held at the
Hurley Hosp tal, Flint, Michigan, May 21, 1941.

The program will include the following papers:

Morning Session

Evaluation of Internal Fixation of Hip Dr. H. B. Elliott

Plaster Paris Technique Dr. J. H. Curtin

Pitfalls in X-ray Diagnosis Dr. R. B. MacDulf

Fractures of the Spine Dr. R. W. MacGregor

Fractures of the Maxilla Dr. F. C. Thorold

12:00 Noon Luncheon at Hospital

Afternoon Session

Internal Two-Plane Fixation of Fractures of Long Bone

Dr. G. J. Curry

The Radiologist in Relation to the Physician. .Dr. L. M. Bogart

Fractures of the Shoulder Region Dr. D. R. Brasie

Osteoporosis and Osteogenesis Dr. J. Livesay

Low Back Pain Dr. O. J. Preston

A round table discussion will follow the presentation
of papers.

Urethral Diverticula
and Cul-de-sacs

By Noah E. Aronstam, M.D.

Detroit, Michigan

Noah E. Aronstam

M.D., Mich-gan College of Medicine, 1898.

Member, Society for InvesCgative Dermatol-
ogy. Member of the Mick'gan State Medical
Society.

■ Urethral diverticula and cul-de-sacs are
anomalies of development and are by no means
so rare as some authorities would lead us to be-
lieve. The literature on this subject is, unfortu-
nately, meager and the little information one does
gain on reading it is very inadequate, so that one
is tempted to regard these defects at best as but
extremely infrequent ones affecting the urethral
mucosa. Genito-urinary surgeons of vast experi-
ence have treated the subject in a very perfunc-
tory manner and have paid but little attention
to it in textbooks or otherwise. The reason why
these urethral malformations are not oftener
encountered may be explained by the fact that
they give rise to no inconvenience in the patient
under normal conditions, and are only acciden-
tally discovered while examining the urethra for
some other malady. Finding nothing of interest
recorded in the literature, I have relied solely
upon my own resources in the elaboration and
description of the subject designated by the title.
This article is largely based upon a number of
cases witnessed by me in my private practice.

Varieties

There are two forms of these urethral peculi-
arities, viz. : ( 1 ) the diverticulum, a short linear,
narrow, collapsible pocket opening into the ureth-
ral canal, from two to three centimeters in length,
of the caliber of a knitting needle, unyielding and
nondilatable ; and (2) the cul-de-sac proper, a
larger, longer and more distended pouch stopping
abruptly or rather terminating blindly in the
mucous lining of the urethra, seldom exceeding
three centimeters in length and somewhat larger
than the preceding one in caliber. Both of these
varieties are congenital anomalies, rarely found
further down than the first two inches of the
anterior urethra and are in most instances situ-
ated on the floor of the canal, thus distinguish-
ing them from enlarged and patulous urethral

May, 1941

355

URETHRAL DIVERTICULA— ARONST AM

follicles that are commonly located on the roof
of the urethra, in proximity to the fossa navi-
cularis.

Embryology

Of interest to the histologist is the embryologic
phase of these small developmental errors. The
only plausible theory the author is able to ven-
ture regarding their embryonic evolution, is the
faulty closure of that part of the genital cleft
concerned in the formation of the urethral tract
synchronous with faulty or delayed participation
in the development of the epiblast lining it. In-
stead of the embryonic units uniting and blending
at the proper period, they undergo a process of
interrupted or mal-development and eventuate
into the above-mentioned abnormalities of the
urethral wall. As remarked before, they are
only accidentally detected by means of the ureth-
roscope or as a result of urethral instrumenta-
tion in the form of sounds or similar instruments
employed for therapeutic or diagnostic purposes.
They are apt to engage the point of the advanc-
ing instrument, and if the operator still persists
on meeting these obstacles in forcibly propelling
the sound, he may not infrequently lacerate or
even perforate the blind extremity and thus es-
tablish a channel of communication between the
cul-de-sac and the urethral canal.

Symptoms and Complications

These anomalies give rise to little discomfort,
but when once the seat of inflammatory involve-
ment they may prove annoying and exceedingly
rebellious to treatment, unless they are radically
attacked by the method I am about to outline.

These anomalies may occasionally produce
very vague symptoms, which are apt to puzzle
the physician. They may, for example, simu-
late a mild case of urethritis, while the history
and accompanying symptoms do not at all war-
rant such a diagnosis. They are, moreover,
the cause of many a case of prolonged urethral
discharge, a “urethrorrhea” as it is termed by
some, while microscopic examination reveals
nothing of importance that could furnish a
clue to the existing pathological state. Among
other symptoms occasioned by them in a num-
ber of instances, painful micturition and uri-
nary tenesmus may be pointed out.

Should they become implicated in a gonococcic
process, concomitantly invading other portions

of the urethral tract, they may form the starting
point for strictures of various kinds, particularly
that of the longitudinal or bandlike type; they
may also prove a prolific source of protracted
suppuration, which is persistent and stubborn
and does not seem to yield to the most painstak-
ing and thorough treatment, until the real cause
of the malady is perchance discovered. The uri-
nary stream in these cases of urethral diverticula
is irregular, either radiating and bifurcating, or
thinly rotating and spurting, necessitating some
effort on the part of the patient to expel it.
This is falsely attributed to the presence of a
stricture and erroneously treated for it. Should
the sound, which is chiefly used for the latter
condition, happen to be of small size it may
promptly engage in the opening of the pouch
or diverticulum and refuse to advance, when
the exact nature of the lesion may be readily
ascertained. Other symptoms may be detailed,
but the above are the main ones demanding our
attention.

Treatment

The treatment of these urethral defects is
decidedly simple. It consists in first discovering
the precise location of the sac or canaliculus by
means of the urethroscope. With the urethro-
scope in situ, the lacunar fold is then slit open
with a small knife or tenotome throughout its
entire extent to the very bottom of the urethral
mucosa. Or, after the site of the channel or
sac has been located, a urethrotome may be in-
troduced and by a sweep of the delicate blade,
the pocket divided. Local anesthesia usually
suffices to accomplish this result. As soon as the
fold of mucous membrane has been severed,
this should be immediately followed by the in-
sertion of sounds in ascending sizes until the
largest can be conveniently passed, and left in
situ for at least ten minutes each time. This
must be continued for a week or ten days to
prevent the too premature closure or healing of
the divided edges or subsequent fibrous contrac-
tion, which may ultimately lead to stricture for-
mation. The two lateral bands become atrophied
and at a level of the urethral canal. Rarely is the
fold of mucous membrane so extensive or over-
lapping as to require ablation or removal in toto.
Another method that may be utilized is to dilate
the urethra either with a urethral dilator or what
is still simpler, with a pair of ordinary dressing

356

Jour. M.S.M.S.

MATERNAL HEALTH— COSGROVE

forceps gently introduced and expanded to its
utmost limit — provided, however, that the cul-de-
sac is not situated too far posteriorly — severing
the band of the pocket by means of a very small
scissors and then proceeding in the manner
delineated above.

Conclusions

In all cases of chronic urethral discharge
without any appreciable or assignable cause as
a basis, one must always be on the lookout for
these annoying little anomalies and institute a
thorough investigation for their possible presence.

Factors in Maternal Health

Hospitals and Staff Groups*

By S. A. Cosgrove, M.D., F.A.C.S.
Jersey City, New Jersey

Samuel A. Cosgrove, M. D.
M.D., Cornell University Medical
Colle^ge, 1907; Clinical Professor of
Obstetrics, Faculty of Medicine, Co-
lumbia University ; Medical Director
and Attending Obstetrician Margaret
Hague Maternity Hospital; Attending
Obstetrician Jersey City Medical Cen-
ter; Consulting Obstetrician Christ Hos-
pital, Jersey City; Bayonne Hospital,
Bayonne; North Hudson Hospital, Wee-
hawken; Holy Name Hospital, Teaneck;
Moiintainside Hospital, Montclair; Mon-
mouth Memorial Hospital, Long Branch;
Diplomate American Board of Obstet-
rics and Gynecology ; Fellow American
College of Surgeons; American Assocm-
tion of Obstetrics, Gynecology and Ab-
dominal Surgery; American Gynecological Society; New York
Obstetrical Society; New York Academy of Medicine, et cetera.

■The subject of maternal health is a most
protean one, embracing much more than the
health of individual mothers and prospective
mothers. It connotes the broadest implications
of the inter-relationship between the health of
mothers as individuals and the welfare of their
children, their husbands, the family structure
and the economic and sociologic relation of
family groups to the community. This relation-
ship is reciprocal between the individual and the
broader fields to which I have alluded. Thus,
while poverty and lack of educational advantages
may very directly influence the health of women
as individuals, just so surely may poor health
in the mother, as the center of the family unit,
result in lack of educational and ^bnomic ad-
vantages for her children. Ill health on the

♦Presented at the Annual Meeting of the Michigan State
Medical Society, Detroit, September 27, 1940.

May, 1941

part of the mother reacts disadvantageously on
her environment and on other individuals in her
orbit just as surely as unfavorable environment
contributes to poor health in the individual.

It is thus very evident that it is quite impos-
sible to examine and discuss all these multifarious
relationships in a brief talk. Rather, many in-
dividuals must contribute thought, each in rela-
tion to his own phase of this manifold sub-
ject. Therefore, it would seem to me proper to
discuss hospitals and doctors as the one phase
most familiar to me, and probably to most of
the rest of us here.

Service to Public

One quite naturally perhaps, first thinks of
the hospital in terms of its service directly to
the physical health of individuals. This has been
and must continue to be the primary channel
through which hospitals serve society. It no
longer, however, by any means, remains the
only channel of such service, nor the hospital’s
only obligation. The concept of the service of
hospitals to the community has broadened com-
mensurately with the broadening of the concept
of the relation of ill health through the individual
outward to the whole of society. Thus, the hos-
pital of today must administer not only to the
physical needs and welfare of its clients, but
must contribute actively and effectively to the
amelioration of the economic and sociologic han-
dicaps under which that clientele exists, and per-
haps most importantly of all to the education
of everyone concerned with the health program,
not only those for whose benefit that program is
inaugurated and carried on, but in relation to
every individual who in any sense contributes
to that program by thought, energy and skill.
For it has been well said that if the whole
broad effort toward bettering maternal health
could be epitomized in one word, that word would
be “education.” Therefore, the hospital which
undertakes, no matter how effectively, to care for
the physical needs only of its clients, and fails to
undertake the education of those clients, and of
the hospital administrators and doctors and
nurses and social workers, it is but doing a poor
half of the complete job which it might be and
should be accomplishing.

The whole program contributing to maternal
health is in its theoretical set-up, well known to
all of you. The agenda and standards established

357

MATERNAL HEALTH— COSGROVE

by the Federal and State Bureaus of Maternal
and Child Welfare, the American Medical As-
sociation, the American College of Surgeons,
the American Hospital Association, the American
Committee on Maternal Welfare and many
others furnish on the whole, not only sufficiently
broad and complete programs, but also adequate-
ly and specifically worked out technical detail.
Hospitals have therein an undeniably important,
indeed a potentially central and commanding
place. This at once imposes on hospitals, and on
hospital staffs, not only the obligation of measur-
ing up to the high potentiality thus accorded
them, but an opportunity by so doing, of contrib-
uting to community and social betterment in a
manner and to a degree tremendously more sig-
nificant than that which could possibly arise out
of a concept of their possibilities for service re-
stricted to the merely physical necessities of their
clients.

For them to develop to its fullest extent this
glorious opportunity, however, every member of
every hospital staff must have a clear and splen-
did vision thereof. Lest some may not have, I
would invite your attention to a fairly broad plan
according to which hospitals and hospital staffs
may contribute to the complete social effort in
behalf of better maternal health, and point out
to you where, in my opinion, it is probably neces-
sary to place especial emphasis in order that the
contribution of hospitals thereto may be, as near-
ly as possible, complete and perfect.

Plan for Service

Physical Equipment. — Every hospital under-
taking the responsibility of caring for maternity
cases must first of all look to its physical equip-
ment which must at least measure up to the mini-
mum standard of the American College already
familiar to you. The plant should be so arranged
as to permit the physical segregation of maternity
cases from all other groups of patients. Separate
labor rooms, delivery rooms and operating rooms
for maternity patients should be provided and
adequately equipped. Separate nurseries for the
newborns must be provided and special attention
should be given to the facilities for the care of
the premature newborn. Laboratory facilities and
service must be adequate to care not only for
the routine but for the emergent demands neces-
sary to meet obstetric catastrophe day or night.

Stajf Organization. — The staff should be or-
ganized so that there is a separate obstetric staff
headed by the best qualified obstetrician avail-
able. In him should be vested the responsibility
for, and authority over, all the obstetric work
done in the hospital, including the private serv-
ice. Ideally in addition to professional compe-
tence he must possess much strength of character
and no little diplomacy. If such a man may not
readily be found on the hospital staff then he
should be imported, or developed, if necessary,
with the assistance of available local consultants
from outside the staff, or of nearby universities,
state departments of health, or other agencies. A
most important part of his responsibility is to set
up standards of technic and principles of man-
agement for that particular hospital. There are
abundant models for such standards and prin-
ciples in material already published. These pre-
sent enough variety in detail to be applicable to
the peculiar needs of any hospital. But it is fre-
quently advisable to conform in general outlines
to established practices in convenient areas, as
is done in some states, for instance, under the
leadership of the State Medical Societies.

These standards and principles having been
set up and properly published, the obstetric
chief of staff must see to it without flinching
from his sometimes difficult duty that
EVERYONE delivering women in the hos-
pital is rigidly required to conform thereto.

Herein his authority must have the unequivo-
cal backing of the hospital administrative board
and executive officers. While we are assured by
spokesmen for hospital administrators that the
latter are awake to the need for protecting the
welfare of obstetric patients, it is to be feared
that this awareness is not universal. In hospitals
in which it does not exist, the hospital staff
must try to establish and strengthen it.

Important in the management set-up is the re-
quirement for competent consultation before any
cesarean section or other artificial delivery pro-
cedure is undertaken. This means, of course,
consultation with one or more competent obstet-
ricians. But if progress in staff organization
and training has made that impossible, the con-
sultation should still be ohstetrically competent.
For if dependence must be upon general sur-
geons, for God’s sake let their conscience be so

358

Jour. M.S.M.S.

MATERNAL HEALTH— COSGROVE

quickened that they cease to think of cesarean
section as a routine procedure of utmost surgical
simplicity. Let them rather be as anxious to
acquaint themselves with the variety of newer
technics for the operation as they undoubtedly
are ready to follow the newer developments of
gastric surgery. Let them be as well founded in
their knowledge of the indications and contra--
indications for each as they are familiar with
the application of various technics of limb am-
putations. If a man undertakes to do obstetric sur-
gery, let him at least learn something about ob-
stetrics in the same sense as he would have to
learn something about thyroid disease in order
to properly perform thyroid surgery.

Hemorrhagic Emergencies

Another important set of regulations concerns
the routine safeguards which must be thrown
around every bleeding case. These include com-
plete organization of material and personnel to
handle hemorrhagic emergencies as follows :

Every bleeding case should be considered
as potentially in extremis and treated on this
basis.

Treatment should be first prophylactic. While
many types of bleeding are accidental and cannot
be anticipated, some of the most serious types
would appear to depend upon, or occur in asso-
ciation with toxemias, especially of the hyper-
tensive and nephritic varieties. This fact implies
the opportunity of guarding against them by
proper prophylaxis of the underlying or associ-
ated toxemic states. The more effective the pro-
phylaxis of toxemias, embodied in close prenatal
supervision, and the radical management of rap-
idly progressive cases can be made, the better
the patient is protected against hemorrhage.

A further detail of prophylaxis is the routine
blood grouping of all antenatal patients at the
earliest opportunity in order to anticipate the
need for it after bleeding occurs, when time is
precious. Such routine blood grouping will even-
tually be considered as much a part of competent
prenatal observation as urinalysis and blood pres-
sure readings.

Prenatal patients should be taught the serious
significance of all bleeding of pregnancy. Prompt
report must be made of its occurrence. Patients
and family must cooperate in accepting bed rest.

hospitalization and other anticipatory and active
treatment.

The final and most important factor of pro-
phylaxis is the organization of policy, personnel
and equipment to handle hemorrhagic emergen-
cies in the quickest and most efficient way. Any
institution upon which devolves the care and
treatment of pregnancy and parturition must pos-
sess such an organization to fulfill that respon-
sibility. Day and night someone must be instant-
ly available with authority to put the plan of
treatment into immediate operation. Twenty-four
hours of every day laboratory personnel and
equipment should be available for grouping and
cross matching of bloods without loss of time.

Equipment and supplies for venoclysis and
blood transfusion should be provided and pre-
pared so as to make their use available as rapid-
ly as is consistent with technical safety. Medical
and nursing personnel familiar with their use and
competent to employ them should be constantly
on duty or subject to instant call. Arrangements
should exist permitting prompt call upon a known
source of available donors. Funds must be made
available to buy blood if and when necessary.
No patient should die for lack of a fifty dollar
bill.

There is no detail of this apparently formi-
dable, but really simple, organization which
cannot be provided in the smallest and poorest
hospital if someone will only see that it is
provided. The largest and most elaborate hos-
pital cannot afford to neglect its provision.

Forceps Deliveries

The next item of regulation must be the super-
vision of all forceps deliveries, because dependent
upon such competent supervision, the use of the
obstetric forceps may differ as between wantonly
murderous butchery and life-saving art.

It does not suffice, in this connection, merely
to have written rules that for instance Group
A of the staff may do difficult forceps oper-
ations, but that Group B of the staff may do
only “low” forceps operations.

For the members of Group B, whose privilege
and responsibility it is desired to limit, are the
very individuals who are least able to distinguish
between dangerously difficult procedures and in-

May, 1941

359

MATERNAL HEALTH— COSGROVE

nocuously easy ones. They are least able to eval-
uate indications and conditions. Therefore, to sup-
plement established rules, actual knowledge of
each situation must be available to the responsible
director and he must give or withhold permission
in each case, and in relation to each operator, un-
less he knows enough of the latter’s capacity to
accord him carte blanche.

^ Standards of Technic

Next must be established standards of technic
for medical and nursing procedure in the labor
rooms and the delivery rooms to which all oper-
ators and other personnel must be required to
religiously adhere.

Nor will the mere establishment on paper of
such standards as I have indicated be adequate to
produce good results. Those responsible for them
must be imbued with the deepest sense of the
necessity of their conscientious execution. And
machinery must be provided for insuring that
their execution is enforced on those individuals
not sharing the proper sense of their necessity
and desirability. The best such machinery on
any except the very smallest services are well
trained obstetric residents, capable of accurate
observation, dependable evaluation of situations,
and invested with definite authority as repre-
senting the service chief or chiefs. Such individ-
uals are invaluable coordinating links between
those possessing responsible authority and those
carrying out the actual procedures of obstetric
practice, in no matter what capacity and in re-
lation both to ward material and their own pri-
vate patients.

Here I wish to emphasize that there should be
no essential distinction between public ward cases
and private patients. The hospital owes the same
duty to each. A private patient is just as much
entitled to have adequate safeguards thrown
about her by the hospital as is the ward patient,
even though she has selected voluntarily a par-
ticular practitioner as her private attendant. The
hospital must see to it that he renders to her a
service not less than it insists be rendered to non-
private patients. If the profession is to properly
cooperate in safeguarding maternal welfare in
the highest possible degree,- a// doctors must be
made to realize the importance of service stand-
ards directed to that objective. I am a private
practitioner myself, deriving far the larger part
of my income from private practice; I have

360

just as strong individualistic tendencies and just !
as great jealousy for my prerogatives in relation |
to my patients as any practitioner can have. Yet !
I believe with the strongest conviction that the ;
zealously guarded relationship between doctor I
and private patient is in the last analysis of less '
importance than the responsibility of society, ;
through the hospital, to insure that every preg-
nant woman receives in parturition the very best
service that careful consideration and thorough
organization by responsible and qualified agencies
can supply.

Furthermore, I am confident that in accepting
that attitude and conscientiously conforming to
properly thought out and established standards
of practice the individual practitioner will in the
long run be conscious of better service to his
patients and greater satisfaction in that service
to them than if he insists on maintaining the tra-
ditional attitude of untrammelled responsibility
for and uncontrolled discretion in handling his
private work.

The inauguration and prosecution of such a
program will undoubtedly entail much bit-
terness, jealousy and misunderstanding at first.
Ideal relationships cannot be accomplished
over night. Much continuous patient effort
will be required, much grief and opposition
may frequently have to be overcome, before
it is accomplished. But accomplished it must
be in every hospital and by every staff before
each can proudly say, “We are accomplishing
our job in the very best possible way for the
safety of our mothers and babies.”

Prenatal Care

The program thus outlined for safeguarding
mothers and their babies in actual parturition
must now be extended to include the means of
safeguarding them in pregnancy and the puerper-
al period after their discharge from the hospital.
Prenatal clinics are just as essential a part of the
hospital’s contribution to maternal health as is
proper provision for the care of the woman in
labor. That this is so requires but little evidence.
Heaton states that it is a consensus of both Brit-
ish and American authorities that efficient pre-
natal care would reduce maternal mortality fifty
per cent. Bierman says that at least half of the
annual loss of twelve thousand mothers directly
due to pregnancy is needless, and that every

Jour. M.S.M.S.

MATERNAL HEALTH— COSGROVE

year that well organized programs for supplying
good prenatal and postnatal care and skilled ob-
stetric care and delivery continues will give us
additional proof that many of these lives can
be saved.

Quigley says that as a result of a nation-
wide coordinated effort between public health
agencies, hospitals, and private physicians,
there has been a very significant decline in the
maternal death rate for the whole country.

Between 1930 and 1936 this decrease amounted
to 15 per cent. Between 1936 and 1938 there
was a further decrease of 24 per cent. In ten
years, from 1928 to 1937, there was a reduction
of 50 per cent in some of our larger cities. New
York, Connecticut, New Jersey, and Pennsyl-
vania, in periods of from four to nine years end-
ing in 1938, showed an approximate average im-
provement of about one-third. Conversely, evi-
dence is abundant that lack of competent prenatal
care is closely associated with high maternal mor-
tality. Thus Bingham says that in 1939, through-
out the whole of New Jersey, 35 per cent of the
obstetrical patients who died had little or no pre-
natal care. Quigley says that the greatest need
for tightening up the program of adequate care
for maternal health is to educate the laity to the
necessity of availing themselves of existing op-
portunities for prenatal care. In our own clinic
to the end of 1939 there were twelve deaths in
168 cases of eclampsia. Of these twelve deaths,
nine had essentially no prenatal care and two
more had only questionably adequate care. In
other words, more than 90 per cent of our
eclamptic fatalities had failed to avail themselves
of facilities for prenatal care which are abundan'
in their community.

Postnatal clinics, while not so definitely related
to immediate maternal mortality as are prenatal
clinics, -are nevertheless of greatest usefulness in
minimizing post-parturient morbidity by follow-
up check of the health of those who have exhib-
ited toxemia in their pregnancies ; they should
in a certain degree protect handicapped women
against the hazard of future pregnancies ; and
they should prevent and cure many gynecologic
morbidities and sequelae.

In connection with the prenatal and postnatal
clinics the development of a field nursing service
is important. The significance of the role of the

public health nurse as a channel of the vitally
important program of education of the laity is
becoming more and more recognized. In this
contribution the public health nurses represent-
ing the hospital should share with the nurses rep-
resenting official public health agencies. In most
cases it is possible and advantageous for the hos-
pital to be the hub about which are correlated all
community efforts in safeguarding maternal and
infant health.

Education of the Laity

Space and time will not permit an adequate
discussion of this great need for education of
the laity in respect to the vital importance of
early and consistent prenatal care. Every com-
mentator on the conservation of maternal health
recognizes this phase as of the utmost importance.
But it has so far constituted the weakest link in
all programs for maternal health betterment and
must in the future command the constant patient
effort of all interested workers to strengthen.
Quigley says that it is “above all” important in
the broad educational program which must go
hand in hand with technical programs for the
protection of maternal health. He suggests the
use of multifarious channels for such lay educa-
tion ; parent-teacher associations and other
groups ; education by literature, such as mothers’
guides ; by exhibits, such as that at the World’s
Fair; by radio; through physicians; through
public health nurses ; through organized effort
subsidized by state and federal public health
agencies. Hospitals cannot neglect to have their
commanding share in this program. Quigley
further says that he believes that further im-
provement will come chiefly in two ways, the
first of which is education of women to seek pre-
natal care early, continued emphasis on the text,
“If pregnant, see your doctor early.”

In addition to the cooperative part which hos-
pitals have toward educational programs par-
ticipated in by other agencies, the hospital has a
very special educational field which is solely its
particular responsibility. There are several .
phases of this teaching activity, but I will not
discuss in detail those relating to nurses, social
workers, laboratory technicians, medical libra-
rians, etc. I do, however, wish to emphasize the
responsibilty of every hospital, no matter how
small or where located, for active participation in
the education of physicians. The size, amount of

May, 1941

361

MATERNAL HEALTH— COSGROVE

material handled, and other circumstances will
determine how broad this education effort may be
in relation to each particular institution. But
every hospital can and should contribute to it in
some degree.

Education of the Physician

The role of the hospital in the education of
physicians is a continuation of, and just as. im-
portant as, the role of the medical college in that
education. The physician who serves the hos-
pital as resident or intern has just as much right
to look to the hospital for supplying this function
as he has to expect it from his medical college.
The responsible heads and other members of the
medical staff of every hospital should recognize
their responsibility in this regard and should ex-
pect to assume the role of teacher as inevitably
and naturally as though they held appointments
to organized teaching faculties. Larger hospitals,
in fact, should have organized teaching faculties,
while the staffs of all hospitals should just as
definitely assume the responsibilty for organized
teaching. ^

Such a teaching program should be based on
a regular curricular skeleton. Appointed periods
for certain parts of it should be fixed. It may
well include a certain amount of formal, didactic
teaching. It should be designed to provide a
generous amount of practical teaching. This
should include ward rounds, manikin demonstra-
tions, informal discussions, conferences in which
cases shall be reviewed, group experience an-
alyzed, mortality thoroughly and frankly dis-
cussed. The indications for operative procedures
should be carefully evaluated and expressed.
Regular periods for pathological teaching and the
study of pathologic material should be provided'

Under the chiefs of service, less experienced
assistants should be given the opportunity of in-
dependent responsibility and constantly broaden-
ing opportunity for practical work, in order that
they may be prepared to substitute for, and even-
tually supersede, the chiefs themselves. These
younger staff men, and the residents, should
share in the teaching program in order that by
teaching they themselves may learn.

Education of Interns

The assignment of interns, except in institu-
tions so small as to make it impossible, should be
on the basis of full time devoted to the obstetric

division. Good work cannot be accomplished
when the attention of the interns to the obstetric
division shares the interest and time devoted to
other work. The interns should be required to
avail themselves regularly of the provided op-
portunities for learning. Private as well as ward
material should be available as the basis of this
teaching. Private attendants should be expected
to be willing to discuss their cases frankly and
fully with the students. The interns should be
permitted to thoroughly know the background
and conditions of private patients as well as
public patients. They should participate in their
management, both in the labor rooms and the de-
livery rooms. They should be permitted to make
rounds on them and to share with their own at-
tendants the interest in, and management of,
their postpartum course.

If you will permit me to quote what I have
already said elsewhere, it is in relation to this
opportunity for teaching that “primary re-
sponsibility touches every one of us. There is
some way that we can all contribute to the
education of doctors after the medical schools
are through with them. We can all teach! It
is enjoined on us in our Hippocratic oath. It
will contribute more to us than to our students.
Any individual on a hospital staff, or any staff
group, can set up formal and practical teaching
of interns and of residents which will repay
manifold the sacrifice that it costs. ... If by
awakening the teaching conscience of all who
are, or might be teachers, the entire material
available for obstetric teaching were properly
developed, the contribution to the competency
of American practitioners would be tremen-
dous, and the effect in better results of ob-
stetric experience would save much unneces-
sary mortality and morbidity.”

Summary

1. Hospitals exist primarily to directly con-
serve and restore the physical health of indi-
viduals. In a broader sense, however, they hav^
an important part in the many-phased sociologic,
economic, educational community activity bearing
upon improvement of maternal health.

2. Directly concerned with the individual wel-
fare of patients is the physical organization and
facilities provided by the hospital for obstetric
patients.

362

Tour. M.S.M.S.

MASTOID OPERATIONS— BRUNNER

3. The next and possibly more important ne-
cessity for good obstetric results is proper staff
organization and control. This should have the
wholehearted endorsement of the management,
and rigid support of the executives, of the insti-
tution.

4. As part of this staff organization, stand-
ards of technics and principles of management
should be established. They should include :

a. Requirement for competent consultation
before the employment of any artificial de-
livery procedure;

b. Adequate safeguards for bleeding cases ;

c. Special control of forceps operations ;

d. Establishment of technical routines in
labor and delivery rooms.

5. Establishment of such standards and prin-
ciples must be implemented by necessary ma-
chinery and authority for their enforcement.
They must be enforced in relation to private pa-
tients as well as to public patients.

6. Prenatal and postnatal clinics and field
nursing services should be set up and operated
by the hospitals.

7. Finally hospitals have a great educational
responsibilty ; important among the objectives of
this responsibility is that of joining with other
agencies in continued intensified effort to im-
press the laity with the importance of early pre-
natal care.

8. While the hospital also has the responsibility
of education of nurses, and other quasi-profes-
sional personnel, its highest and specific educa-
tional function is the continuing education of
physicians. This function applies to members of
its own staff. Most importantly, however, it ap-
plies particularly to its interns. In relation to
these men and women it supplements and con-
tinues in integral relationship their medical col-
lege training.

BibKography

1. Adair, F. L. : Maternal Care and Some Complications. Chi-
cago: Univ. Press, 1939.

2. Amberg, Ray M.: Social aspects of maternal and child

health from standpoint of hospital administration. Hospitals,
13:42, (Jan.) 1939.

3. Bierman, Jessie M. : Recent advances in maternal and

child health. Hospitals,, 13:42, (Feb.) 1939.

4. Bingham, A. W. : The report of the advisory committee on
maternal welfare. Jour. Med. Soc., New Jersey, 37:247,
(May) 1940.

5. Clifford, Martha L. : The State Department of Health

maternal care program. Jour. Conn. State Med. Soc., 3:567,
1939.

6. Cosgrove, S. A.: An opportunity and obligation. Jour.
Med. Soc. New Jersey, 37:369, (July) 1940.

7. Ibid: Obstetric hemorrhage and its management. So. Med.
Jour., 29:1219, (Dec.) 1936.

8. Daily, E. : Standards of prenatal care. Bull. No. 153,

U. S. Gov’t Printing Office, Washington, 1939.

May, 1941

9. Fl'^^'^t) Marion. A. : Securing early antepartum care. Pub-

lic Health Nursing, 32:28, (Jan.) 1940.

10. Gerdes, Maude M.: Newer concepts and procedures of

maternal care. Am. Jour. Public Health, 29:1029, (Sept.)
1939.

11. Hall, .Beatrice: Maternity care as a community problem.

Hospitals, 13:16, (Jan.) 1939.

12. Honey, T. Paul, Jr.: Maternity program in Pike County.
Miss. Doctor, 17:49, (Aug.) 1939.

13. Heaton, Claude Edwin: Modern Motherhood. New York:
Farrar & Rinehart, Inc., 1935.

14. Leuroot, Katherine F. : Federal and state cooperation in

maternal and child health. Jour. Mich. Med. Soc., 38:
1088, (Dec.) 1939.

15. Quigley, James Knight: Maternal welfare, what are its

fruits? Am. Jour. Obst. and Gynec., 39:349, (Feb.) 1948.

16. Seibels, Robert S. : Report of Committee on Maternal Wel-
fare. Jour. South Carolina Med. Assn., 35:20'2, 1939.

Indications for Simple and
Radical Mastoid Operations*

By Hans Brunner, M.D.

Chicago, Illinois

Hans Brunner, M.D.

Associate Professor of Otolaryngology,
University of Illinois, College of Medi-
cine; Docent at the University of Vien-
na; formerly Chief of the Otolaryn-
gological Department at the Allgemeine
Poliklinik in Vienna; formerly Presi-
dent of the Austrian Otological Society;
Honorary member of the Ameri-
can Academy of Ophthalmology and
Otolaryngology ; Member of the Col-
legium Otolaryngologicum.

■ The operations on the mastoid process are
prophylactic operations. Neither the inflamed
mastoid process in an acute otitis nor the scle-
rotic mastoid process in a chronic otitis is dan-
gerous to the life of the patient. However, in
both circumstances there is danger that the infec-
tion will pass over towards the structures adja-
cent to the mastoid process, namely, the meninges,
the sinus of the dura, and the brain. From that
point the life of the patient is in danger. That is
particularly true for the acute mastoiditis fol-
lowing an acute otitis. Consequently, it is the
task of the otologist to save the meninges and
the brain from becoming infected, which is pos-
sible in a great number of cases (of course not
in all) since, as a rule, the infection in the mas-
toid process does not attack the meninges, unless
it reaches a certain degree of maturity. It takes
about four weeks from the onset of the acute
otitis to reach that degree of maturity. A mas-
toiditis in that stage is often called “coalescent

*From the Department of Laryngology, Rhinology and Otology,
University of Illinois College of Medicine, and the Research
and Educational Hospitals.

Presented at the Annual Meeting of the Michigan State Medi-
cal Society, Detroit, September 26. 1940.

363

MASTOID OPERATIONS— BRUNNER

mastoiditis” and it presents a great number of
definite symptoms. Therefore it should be easily
recognized by the general practitioner.

Coalescent Mastoiditis

The symptoms of the coalescent mastoiditis
can be divided into: (a) General symptoms;

(b) general brain symptoms; (c) local brain
symptoms; (d) symptoms from the mastoid
process; (e) symptoms from the auricle and
from the external canal; (f) symptoms from the
drum and the middle ear.

General Symptoms. — The mental and psychical
conditions of the patient are entirely normal in
adults as well as in children. The temperature
in adults may rise to 101. Higher degrees of
temperature point as a rule to a beginning intra-
cranial complication unless they are due to an-
other disease and indicate the exposure of the
sinus. Chills are missing and the blood count is
normal in adults as well as in infants.

General Brain Symptoms. — Adults frequently
complain of headaches. However, the patients
never point to a particular part of the skull as
the seat of the headaches. The fundi of the eyes
as well as the cerebrospinal fluid are normal.

Local Brain Symptoms. — Pareses, hemianop-
sia, aphasia are strictly absent.

Symptoms from the Mastoid Process. —

The mastoid process nearly always shows
some very important symptoms if it is exam-
ined in the proper way. I recommend the fol-
lowing method of examination : The phys-
ician stands behind the patient and touches
gently the skin of the mastoid process on both
sides. As a rule, the skin of the diseased side
is warmer. After having examined the tem-
perature of the skin the physician looks for
an edema on the tip of the mastoid process.
That is the most difficult part of the exami-
nation and requires some training. One has to
have in mind that the outer surface of the tip
of the mastoid process is covered only by
periosteum and thin skin. There is no sub-
cutaneous fat, not even in individuals with a
fat neck. Consequently, the outer surface of
the tip always can be felt as a clear-cut bony
edge, provided the patient slowly moves his
head to both sides in order to relax the con-

traction of the sternocleidomastoid muscle.
In a mastoiditis the periosteum of the tip is
infiltrated and swollen. Consequently, the
tip can not be felt as a clear-cut edge, and one
rather gets the impression that between the
bony edge and the finger of the examiner there
is edematous soft tissue which leads to the
diagnosis of an edema of the tip of the mastoid
process. Although it requires a certain train-
ing to become acquainted with that kind of
examination, I consider the edema of the tip
as the most important mastoid symptom and I
believe that the number of cases of so-called
latent mastoiditis would decrease considerably
if otologists would always stress the proper
importance of this part of examination.

Less important is the tenderness of the mas-
toid process which many textbooks emphatically
call the chief symptom of the mastoiditis, al-
though the tenderness may be almost entirely
missing in mastoid processes with a thick corti-
calis. However, if it is present one has to expect
it on the tip, but not on the planum of the mas-
toid or in the region of the antrum. Frequently
I observed otologists exerting a formidable pres-
sure on the planum mastoideum in seeking for
tenderness. There is no doubt that such a pres-
sure hurts. It even hurts the audience. The ac-
tual tenderness can be found by exerting a gen-
tle pressure towards the tip. In the sitting pa-
tient the pressure has to be directed upwards ; in
other words, from the neck towards the mastoid
antrum and not from the outside towards the
midline.

The x-ray picture of the mastoid process
should be taken in every case where there is time
to take it. However, the x-ray picture is not a
conditio sine qua non as far as the diagnosis of
the mastoiditis is concerned. Since the coalescent
mastoiditis in its mature stage produces a very
great number of symptoms in most of the cases,
the diagnosis can also be made without an x-ray
picture.

Symptoms from the External Ear. — It is well
known that in subperiostal abscesses, which oc-
cur more frequently in infants than adults, the
auricle acquires an abnormal position, viz., it is
turned forwards and depressed downwards. The
same position, of course less marked, can be
observed in the mature coalescent mastoiditis

364

Jour. M.S.M.S.

MASTOID OPERATIONS— BRUNNER

without subperiostal abscess. Naturally, that ex-
amination also requires trained eyes.

Of greatest importance is the sagging of the
superior and posterior wall of the external
auditory canal. As a matter of fact, some
otologists call this finding the chief symptom
of the mastoiditis. To appreciate this symptom
one has to know its pathology. The posterior
and superior wall of the external canal is
simultaneously the lateral and inferior walls
of the mastoid antrum. In other words, if the
superior and posterior wall of the external
canal is perforated one enters the antrum.
Consequently, the superior and posterior wall
of the external canal is covered on one surface
with mucous membrane of the antrum, on
' the other surface with the skin of the external
' canal. Skin and mucous membrane are con-
nected by blood vessels which perforate the
bony plate.

Supposing there is an inflammation of the an-
tral mucous membrane. Under these circum-
stances the little veins of the mucous membrane
become involved by a thrombophlebitis and since
some of these veins perforate the bony wall, they
carry the infection from the mucous membrane
into the skin producing a deeply located periosti-
tis of the superior and posterior wall of the ex-
ternal canal. We call this deeply located perios-
titis sagging of the superior and posterior wall of
the external canal. Considering these pathologic
findings the appearance as well as the importance
of the sagging becomes obvious. The sagging is
always situated close to the drum. The skin of
the sagging is white, since the inflammation is
situated in the deep layers of the skin, and it is
not tender to gentle touching with a probe. The
sagging indicates an inflammation of the antral
mucous membrane and most frequently retention
of pus within the antrum. Since retention of pus
accompanies every coalescent mastoiditis the sag-
ging, consequently, indicates a mastoiditis.

Disclvarge. — The discharge in that type of mas-
toiditis is abundant, not fetid. The drum is red,
swollen and veiy^ often shows nipple-like perfo-
rations.

Clinical Progress

There can not be any doubt that this type of
mastoiditis is clinically ver}' well characterized

and there also can not be any doubt that after
having made the diagnosis the case should be
operated on. However, there are instances in
which the operation can not be performed for
some reasons. What happens in these cases ?
These cases either recover spontaneously or they
become subacute, but they never become chronic
in adults in good general health.

Spontaneous Recovery. —

That a coalescent mastoiditis may recover
spontaneously, cannot be earnestly doubted.
Such spontaneous recoveries occurred even
in a time in which the streptococci were not
menaced yet by sulfanilamide or prontosil.
Nevertheless, spontaneous recoveries of com-
pletely developed, coalescent mastoiditis are
not met with frequently.

More often the acute mastoiditis turns over
into a subacute mastoiditis, particularly in older
individuals. Unfortunately, the importance of
that type of mastoiditis is frequently not appre-
ciated. In subacute mastoiditis one finds a de-
crease of clinical symptoms and an increase of
danger to the life of the patient. In typical cases
the symptoms of the mastoid process subside
after the fourth week of the acute otitis. The
tenderness of the tip of the mastoid process de-
creases, the discharge from the middle ear either
becomes scanty or continues to be abundant, in
some cases even the hearing may improve — in
short, in some of these cases the otitis and mas-
toiditis apparently subside or at least improve.
However, that improvement is only temporal*}^
and lasts about one week. The short intermission
of well being comes to an end and most often in
the sixth or eighth week of the otitis the disease
shows its actual face and the patient, and, some-
times the physician, are terribly surprised by a
fulminating complication.

Consequently, the physician must watch the
patient carefully when a completely developed
mastoiditis subsides or seems to subside in the
fourth or fifth week of an acute otitis. That
holds particularly true in older individuals. Al-
though that improvement may be followed by an
actual recovery, one has also to bear in mind that
the acute mastoiditis might turn over into a sub-
acute mastoiditis. In handling these cases the
x-ray examination of the mastoid process is of
great value, since it shows a continual improve-

M.^y, 1941

365

MASTOID OPERATIONS— BRUNNER

merit in cases who are going to recover, and a
continual impairment in cases who are going to
become subacute.

Also a subacute mastoiditis may recover spon-
taneously, particularly in young individuals, al-
though that occurrence is rarely encountered.
More often the subacute mastoiditis leads to a
complication when not operated on in the proper
time.

Hemorrhagic Mastoiditis. — Up till now we
have discussed only the coalescent mastoiditis,
which becomes mature in a period of about four
weeks. However, we know that in some cases
an intracranial complication may show up with-
out a preceding coalescent mastoiditis. That oc-
curs particularly in young individuals with an in-
complete pneumatized mastoid process. In such
cases definite symptoms of a meningitis or a
sinusthrombosis may appear in a very early stage
of the acute otitis. According to my experience
the fourth day of the acute otitis seems to be a
critical day. In opening the mastoid process of
these cases one finds either no pus at all or lit-
tle pus ; there is no or very little necrosis of bone,
but there is much bleeding from the small blood
vessels of the mastoid. Therefore, that kind of
mastoiditis is often called “hemorrhagic mas-
toiditis.”

Mastoidism. — A similar finding is met with
when a well pneumatized mastoid process is op-
erated on in the first week of an acute otitis.
Alexander called these cases “mastoidism,” which
is different from the coalescent mastoiditis as
well as from the hemorrhagic mastoiditis. It dif-
fers from the coalescent mastoiditis in the fol-
lowing points.

1. The mastoidism appears in the first week of
an acute otitis, particularly in children, while
the coalescent mastoiditis appears in the third or
fourth week of an acute otitis, in children as well
as in adults.

2. The mastoidism practically never produces
a sagging of the superior and posterior wall of
the external canal, while the coalescent mastoidi-
tis as a rule does.

3. The mastoidism does not require an opera-
tion, while the coalescent mastoiditis does.

The mastoidism also differs from the hemor-
rhagic mastoiditis, since the mastoidism never is
accompanied by symptoms of a beginning in-

tracranial complication (fever of high degree,
chills, rigidity of neck, et cetera). The hemor-
rhagic mastoiditis, as a rule, is accompanied by
one or more such symptoms.

Chronic Otitis. — The pathological conditions in
chronic otitis are quite different from those in
acute otitis. In the latter the entire mastoid
process is inflamed and, consequently, from every
cell in the mastoid process the infection can be
carried towards the meninges. In chronic otitis,
particularly in these cases which require surgery,
the mastoid process is sclerotic to a great extent
and thus it does not harbor any danger for the
meninges. The pathology in these cases is usually
found only in the petrosal angle, in the antrum
and especially in the middle ear. Consequently,
these parts of the temporal bone are subject to
the radical operation.

Indication for Radical Operation. — The radical
mastoid operation has a relative and an absolute
indication. The relative indication is found in a
chronic otitis affecting the bony walls of the mid-
dle ear and treated with aseptic methods for a
certain period of time without success. That
statement needs some comment. At first, it em-
phasizes the importance of the aseptic treatment
of chronic otitis. It is an old experience that
antiseptic treatment (with exception of the treat-
ment of granulations in the middle ear with al-
cohol) increases the discharge rather than de-
creases it. Consequently, we treat chronic otitis
with irrigations, drainage and hydrogen peroxide
only and we avoid any antiseptic treatment, even
boric acid.

Furthermore, the above statement speaks con-
cerning the treatment of a certain period of time.
To make that statement more exact we have to
say that a treatment of five to seven weeks
is sufficient to find out whether or not the aseptic
treatment will lead to a success. Success in these
cases of course does not always mean to get the
ear entirely dry ; we rather may speak of success
when the discharge definitely decreases and par-
ticularly when the discharge loses its fetor.

The relative indication is most often followed
in patients between twenty to fifty years of age,
particularly if they cannot afford to be under the
care of a specialist for a long period of time. It
is justified to follow the relative indication in
these cases, since we know that suppurations of
the middle ear affecting the bony walls most often

Jour. M.S.M.S.

366

SYMPATHETIC OPHTHALMIA— MARSHALL

lead to an intracranial complication in people
between twenty to fifty years of age. That, of
course, is only true for these suppurations which
are not complicated by a cholesteatoma, since the
cholesteatoma of the middle ear may lead to a
complication in every age of life.

The absolute indication is found (a) when
there are symptoms of an intracranial compli-
cation (b) when there are symptoms of the
suppuration having passed the surgical boun-
daries of the middle ear.

The first indication does not need any com-
ment, but the second does. The surgical bounda-
ries of the middle ear are as follows : Upward —
tegmen tympani ; forward — tegmen tympani and
venous plexus around the carotid artery; down-
\ ward — jugular bulb; backward — mastoid antrum
and facial canal ; mesialward — labyrinth ; lateral-
ward — external auditory canal. Each of these
structures produces definite symptoms when in-
vaded by suppuration. When the suppuration ex-
tends towards the tegmen the patient will notice
headaches of neuralgiform type and slight rises of
temperature. When the suppuration extends for-
ward, symptoms from the tip of the petrous bone
! and sometimes even symptoms of sepsis may oc-
cur. When the suppuration extends downward
(which very seldom occurs), the patient notices
chills. When the suppuration extends backwards,
mastoid symptoms, sometimes a facial paralysis
are found. When the suppuration extends me-
sialward, labyrinthine symptoms occur. When
the suppuration extends lateralwards, ulcerations
in the mesial part of the external canal are
found. These absolute indications should be
followed (a) in patients who are older than
sixty years, (b) in patients with a general dis-
ease as tuberculosis, diabetes, severe arterioscler-
osis, etc., (c) in patients who have a deaf ear
which is not suppurating. The last statement
needs a comment. Supposing there is a patient
who is stone deaf on the right side due to a lues
or a concussion of inner ear or some other rea-
son. If that patient has on his left side a chronic
otitis with some remnants of hearing, an oper-
ation should be performed only following abso-
lute indications. One has to keep in mind that
the radical mastoid operation destroys the rem-
nants of hearing. Consequently, in these cases
one should operate only when there is imminent
danger to the life of the patient.

Sympathetic Dphthahnia*

By Don Marshall, M.D.

Kalamazoo, Michigan

Don Marshall, M. D.

A.B., Bowdoin College, 1927. M.D., Univer-
nty of Michigan, 1931. M.Sc. in Ophthalmol-
ogy, 1935. Certified American Board of Oph-
thalmology, p35. Member, Michigan State
Medical Society.

“ Sympathetic ophthalmia is a rare but serious
disease. A typical attitude toward it is that
of a prominent eastern ophthalmologist with a
heavy industrial practice who told me two years
ago that among 22,000 patients he had had only
two cases of this disease, but that it “scared him
stiff.” Since no man sees this condition very
often, it has been advised that all cases be report-
ed. The purpose of this short paper is to give a
brief case history, and to review the principal
facts that are known today about this important
type of uveitis.

Case History

C. S., a boy of seven, on June 26, 1939, lacerated
his right eye with a knife. Examination an hour later
by Dr. E. P. Wilbur showed a 6 mm. comeo-scleral
laceration below, with iris caught in the corneal wound
and a little vitreous presenting in the 2 mm. scleral
portion. There was a hyphemia. The boy was hos-
pitalized, given 1500 U. of tetanus antitoxin, and treated
with atropine, pad, and three 2 c.c. injections of Om-
nadin. Five days later iris prolapsed below and
was excised. The eye promptly quieted and healed, and
he was discharged on the ninth day after injury, July
6. Atropine, hot compresses and pad were continued
for a month after the injury. There was then slight
photophobia. About that time he began complaining
of discomfort in his left or good eye. When seen
five weeks after the injury, on August 5, the right
eye had keratic precipitates, and the left was irritable.
Both eyes were atropinized, 60 grains of sod. salicylate
started daily, and 60 million typhoid antigen H given
intramuscularly in two days. By the sixth week, when
I first saw him, the left optic nerve had become in-
flamed, that eye had keratic precipitates and cells in
the aqueous, and the right eye showed a more active
uveitis. The boy again was hospitalized, for eighteen
days, tmder treatment with atropine, hot compresses,
salicylates and intravenous typhoid vaccine (eight in-
jections). During this time both eyes became worse,
then better. Soon after discharge, the right eye had
subnormal tactile tension, eleven KP, an edematous
disc with engorged retinal veins, and vision of 15/400.

* Abridged from a paper read before the Section on Ophthal-
mology, Michigan State Medical Society, Detroit, Mich., October
10, 1940.

May, 1941

367

SYMPATHETIC OPHTHALMIA— MARSHALL

The left eye had fourteen small KP, twelve cells per
field, in the aqueous, a blurred disc margin nasally,
slight retinal edema, normal vessels and corrected
vision of 20/15. Both fundi showed peripherally a
fine disseminated chorioretinitis. We have felt no
doubt that this was a true sympathetic ophthalmia.
Except for a slight flare-up a month later in the in-
jured eye, healing has been complete, and the left eye
is today normal except for the healed chorioretinitis.
The injured eye has improved much. Vision now, a
3'ear later, is 20/100 with the right or injured eye,
and 20/15 with the better or second eye.

Definition

Sympathetic ophthalmia may be defined as a
specific ocular inflammatory disease, clinically al-
ways bilateral, that afifects primarily the uveal
tract. With possible rare exceptions, it always
follows a perforating wound of the eye, either
traumatic or operative.

Frequency

Figures on the frequency of sympathetic oph-
thalmia vary. Among all eye patients it is found
only in a small fraction of 1 per cent. But among
patients with perforating wounds it occurs in at
least 1 per cent or more. It is not becoming
less frequent.^® It shows no significant variations
as to sex, age or season involved. Woods^® gives
the immediately predisposing causes as follows :

Penetrating wounds •. . . .63%

Intra-ocular operations 24%

(about half for cataract)

Subconjunctival scleral rupture 5%

Perforating corneal ulcer 4%

Intra-ocular tumor 3%

Pathology

The histological picture of sympathetic oph-
thalmia is an unusually uniform cellular infiltra-
tion of the uveal tract by lymphocytes and epi-
thelioid cells, with extension to other parts of the
eyeball.

Clinical Symptoms

Usually, at the time of onset of the disease in
the second or sympathizing eye, we find the first
or exciting eye to be inflamed, soft, and with poor
vision. It has suffered an operative or traumatic
wound which has been slow to heal, and there has
been inclusion of uveal or lens tissue in the
wound. It has been subject to recurrent attacks
of inflammation, or a low-grade uveitis. The di-
agnosis is based on evidence of active iritis, the

most important step being careful examination
with the slit lamp.

Etiology

The etiology of sympathetic ophthalmia is not
known. Much study has been done, and consid-
erable evidence piled up in favor of several theo-
ries, but research has been handicapped because
the disease has not been produced in experimental
animals. No theory advanced adequately anc
completely explains all aspects known about the
disease. We mention here the principal theories
under consideration today.

Bacteria. — The disease resulting from an or-
ganism that gains entrance into the eye at the
site of the wound, and moves to the other eye by
blood or lymph stream, or via the nerves. This
theory is very reasonable, and is supported by the
studies of Samuels, which show that the specific
infiltration usually starts at the site of the injury
and spreads from there around the first eye, later
to appear in the second.

Filterable Virus. — It has been possible in rab-
bits, by inoculating the optic nerves at any jx)int
with a virus, to produce a picture resemblingi
sympathetic ophthalmia. The virus definitely
travels along the optic nerves via the chiasm. But
no virus specific for sympathetic ophthalmia has
been proven or found, even in enucleated human
eyes. And here again we can’t explain the cases
without a wound, unless the causative organism
is endogenous.

Allergy. — Alan Woods and the Hopkins School
have done much work on the disease from the
allergy aspect. Uveal pigment is organ but not
species specific. Injected into the body, antibodies
will form, and the body can be made sensitive to
the substance. The theory developed that sym-
pathetic ophthalmia is an allergic reaction in an
individual sensitive to uveal pigment as a result
of previous trauma, or rarely to the presence of
an intra-ocular melanoma. In this condition the
usual antibodies are absent.

Tuberculosis. — Because of the histologic and
clinical resemblance of sympathetic ophthalmia to
tuberculous uveitis, efforts have been made to es-
tablish the common identity of the two diseases.
Most important, J. Meller has recovered’^ tu-
bercle bacilli from the blood and the eye in this

368

Tour. M.S.M.S.

SYMPATHETIC OPHTHALMIA— MARSHALL

sympathetic disease. From his findings he feels
that sympathetic ophthalmia is nothing but a
chronic spontaneous uveitis on a tuberculous ba-
sis, instigated in the first eye by injury to a per-
son with bacteremia, and getting to the second
eye as a blood-borne metastasis.

Diagnosis

The diagnosis is always presumptive,^” and can
never be made positively except under the mi-
croscope. There is no pathognomonic character-
istic. The diagnosis never can be made from the
injured eye. Because uveitis from another cause
may resemble sympathetic ophthalmia, diagnosis
of the latter condition is made more frequently
than the disease actually occurs.

In diagnosis, the history and the time element
are important. Although the condition seldom oc-
curs in less than two weeks after the injury, 44
to 65 per cent develop within two months, and
77 to 90 per cent within the first year.

Therapy

Prevention is the best cure. In repairing in-
juries, all uveal and lens tissue should be care-
fully removed from the wound, and the lacera-
tion covered with conjunctiva. Enucleation must
be done where it is indicated and justified. This
step must be taken within two or three weeks
after the injury if it is to benefit, and promptly
if the disease has already developed.

The problem of whether or not to enucleate an
eye, either at once, or after an attempt has been
made to save it, is difficult. In this connection,
Samuels writes :®

“Sympathetic ophthalmia is of great practical impor-
tance because on the correct judgment of the surgeon,
in cases of injury, the future vision of the patient may
depend. . . . This disease does not occur when the
wound in the injured eye heals correctly and when
the function of the eye is not interfered with. It su-
pervenes in the uninjured eye only when the first eye
shows signs of iridocyclitis as a result of traumatism.
... If one observes, after a perforating wound, that
the eye becomes soft and atrophic, that the cicatrix
on the surface is retracted, that the eye is painful
or sensitive to touch, and that the vision is failing, one
finds in these symptoms an indication for enucleation,
because such an eye has the potentiality of producing
sympathetic ophthalmia.”

It is felt that foreign protein injections have
definite nonspecific value in the prevention of this
disease. The infrequency of the disease in the

last great war has been credited to the routine use
of tetanus antitoxin. Benedict^ says that the pro-
phylactic injection of foreign proteins for the
prevention and treatment of sympathetic oph-
thalmia has been so effective that it should be a
routine procedure in every case of injury where
the eye may be subject to the disease.

The treatment of the actual disease is that of
uveitis, by dilating the pupil with atropine, using
salicylates — as salicylic acid or aspirin in heavy
doses, and foreign protein injections. According
to Verhoeff, the best of these is diphtheria anti-
toxin, 20,000 units daily for a week, and con-
tinued daily or weekly until there is marked im-
provement, or the patient has an anaphylactic re-
action. Typhoid vaccine and boiled milk have
also stood the test of time.

Prognosis

In general, under intensive and proper therapy,
the prognosis in sympathetic ophthalmia today
isn’t as bad as it used to be, but in a given case
no very hopeful promises can be made. The dis-
ease in children is very severe and the outcome
unsatisfactory. The same is true of the disease
following cataract extraction. The results vary
in individual cases because the severity of the
disease varies, and the time of starting and the
thoroughness of therapy vary. Woods on the ba-
sis of 125 reliable cases in the literature finds
that on the average the results in 51 per cent are
favorable, or in 68 per cent if seen early and ade-
quately treated. The process is drawn out, with
relapses, and in that way may show activity for
months or years. At least half of all cases end
up with no or useless vision.

Sympathetic ophthalmia is so rare that no man
sees many cases. To conquer the disease we must
all pool our experience. Though each of us sel-
dom confronts the actual condition, its severity
always makes us fear its coming. I hope only
that this brief resume of the present status of the
disease may stimulate thought and discussion and
thereby help us all.

Bibliography

1. Benedict. William L. : Sympathetic ophthalmia. Surg., Gyn.
and Obstet.. 60:1145-1146, (June) 1935.

2. Butler, T. H. : An Illustrated Guide to the Slit Lamp. New

York: Oxford University Press, 1927.

3. Gifford, S. R. : Modern views of sympathetic ophthalmia.

NeHaska State Med. Jour., 14:432-437, (November) 1929.

4. Irvine, Rodman: Sympathetic ophthalmia. Review of sixty-

three cases. Arch, Ophth., 24:149-167, (July) 1940.

5. Joy, Harold H.: A survey of cases of sympathetic ophthal-

mia occurring in New York State. Arch. Ophth., 14:733-
741, (November) 1935.

May, 1941

369

SYMPATHETIC OPHTHALMIA— MARSHALL

6. Joy, Harold H. : Prognosis of postoperative sympathetic

ophthalmia. Arch. Ophth., 17:677-693, (April) 1937.

7. Meller, J. : Successful demonstrations of the tubercle

bacillus in the stained section of an eye with sympathetic
uveitis. Ztschr f. Augenh., 89:1, (April) 1936. (Abstr. by
H. Gifford, Jr., Arch. Ophth., 19:443, (March) 1938).

8. Samuels, Bernard: Notes on the pathology and surgical

treatment of sympathetic ophthalmia. Arch. Ophth., 15:59-
69, (January) 1936.

9. Samuels, Bernard: Sympathetic scleritis. Arch. Ophth., 10:
185-197, (August) 1930.

10. Theobald, Georgiana D.: Frequency of sympathetic ophthal-
mia. Am. Jour. Ophth., 13:597-604, (July) 1930.

11. Trowbridge D. H., Jr.: Sympathetic Ophthalmia. Am.

Jour. Ophtn., 20:135, (February) 1937.

12. Woods, .Man C. : Allergy in its relation to sympathetic

ophthalmia. New York State Jour. Med., 36:1-16, (Jan-
uary 15) 1936.

13. Woods, Alan C. : Sympathetic ophthalmia. Am. Jour.

Ophth, 19: Part I, 9-15, (January), and Part II, 100-109,
(February) 1936.

BOTULISM

“The truth is that botulism is very largely a bugbear.
The word itself sounds wonderful on medical lips.
Real cases are alarming enough to cause considerable
noise when they appear, and so the name gains cur-
rency and is bandied about freely both by those who
cannot, and those who ought to, know better. Actually
botulism is a comparatively rare disease. Between 1899
and 1922, when the United States Public Health Serv-
ice’s report was issued, only 345 cases were reported
in the whole of this country and Canada. And some
of these were doubtful.

“No amount of sheer luck could have led the com-
mercial canners virtually to eliminate botulism as a
lurking peril in their products. It was a matter of
hard work and indefatigable ’ research over many dec-
ades. Preservation of food by heating and enclosing
in containers — for that is practically what canning
means — was discovered by a Frenchman named Nic-
olas Appert as long ago as the beginning of the last
century. In 1841, canning was established in the
United States ^s an industry, and since that time has
been slowly but surely advancing to a state of per-
fection in safety, Louis Pasteur lived, worked, and
died, and availment was made of his bacteriological
discoveries. It was known at least why heat sterilizes,
and the degrees of heat necessary to sterilize different
substances were worked out and recorded. This busi-
ness of sterilizing canned foods is called “processing,”
and nowadays any food material put out in containers
^ by reputable canning firms is practically always prop-
erly and scientifically processed, and sterile and whole-
some, and will remain so as long as the can is un-
opened, undamaged, and kept free from rust. If a can
rusts, of course, the rust will eat into the tin and
in due time it will be perforated.

“For a long time the choice of the container was one
of the commercial canner’s chief sources of headache.
Originally glass was used — as in home canning — and
Appert was wont to seal up his preserved material in
jars with corks. Then the tin can was invented and
two styles of container were evolved — the so-called
vent-hole can and the open-top can. Of these the
former, which is closed with solder, is the earlier type,
and its use has now been practically abandoned for
everything except certain meats and evaporated milk.
The open-top can, now generally used, is covered after
the filling is done and is immediately sealed with a kind
of cement. Sometimes a paper gasket is also introduced
to make the can air-tight, and, where rusting is likely,
the cans are enameled on the outside. The paper
lining we find in tins containing crab and other sea
food is there simply to prevent discoloration through
contact with the metal. The shellac coating of the
inner surface of some cans is applied in order to pre-
vent the very kind of blackening (which was men-
tioned in the Monahan case).

“In older days, when the art of canning was not so
far advanced as it is now, the pressure and tempera-
ture to which a large can was subjected would some-
times cause the- seam to open slightly, and if this con-

370

dition went unnoticed the contents of the can would
be invaded by bacteria and would in time undergo
spoiling. When such a leak occurs the can, after
processing, will show little drops of moisture at the
site of the leak. This is called “sweating.” Nowadays
every can is inspected for “sweating,” and if it is pres-
ent the can is tightened and reprocessed, or eliminated.
Besides, containers are now more strongly made than
formerly; so this possible source of contamination has
all but vanished in reputable canneries. Two other
ways, and two alone, remain by which commercially
preserved food may reach the consumer’s table in a
decomposing condition. The first is through the can-
ning of food already spoiled. But this is most unlikely
if the can is put out by an established firm, since
packers simply cannot afford to put out under their
label, material which is not above suspicion. The sec-
ond is through underprocessing in which some of the
bacteria escape destruction. This possibility still exists
of course, and “blown” cans are sometimes seen.

“So far as poisoning is concerned, decomposition
must be fairly far advanced before the contents of a
can becomes toxic. In the last fifteen years I have
investigated countless charges against the companies.
Yet in all that time I have not encountered an au-
thentic case of poisoning of any kind traced to com-
mercially canned food ; and I have yet to hear of one,
although the contents of millions of cans is consumed
daily throughout these United States.” — The Poison
Trail by William F. Boos, M.D.

THE FIRST ESSENTIAL
An Authorized Code of Conduct

On Friday, April 4, a Federal Jury in Washington,
D. C., found the American Medical Association guilty
of “a criminal conspiracy to restrain trade.”

The Jury exonerated five officials of the A.M.A. and
fourteen distinguished physicians of the District of
Columbia.

Practically, this verdict is without precedent and ulti-
mately, it may vitally affect every practicing physician
in the United States. It is essential to the continued
effectiveness of American Medicine that physicians —
every physician — understand and be concerned about
the verdict of this jury and the meaning and implica-
tion of the issues involved in this unprecedented prose-
cution.

In effect, the Federal Jury found that :

Organized medicine had entered into a conspiracy —
a criminal conspiracy — but that there were no con-
spirators ;

A crime had been committed — but that there were
no criminals ;

Trade had been unlawfully restrained — but that there
were none responsible for the restraint.

As far as a settlement of the issues is concerned, the
verdict is without sense or substance or meaning. How-
ever, as the trial progressed and the evidence was pre-
sented by the attorneys for the prosecution, the issues
were clarified and defined and the purpose and objec-
tives of the prosecution became apparent. The attain-
ment of these objectives would destroy the structure
and pattern of medical service as it has been known
and accepted in the United States.

Tediously, step by step, over a period of more than
a century, American Medicine evolved and established
codes and principles which governed the providing of
medical service.

In the establishment of the principles, no legal au-
thority was involved. There has been no compulsion in
the controls. They were voluntary. They became oper-
ative and effective because they answered a need and
worked successfully. — From “The Two Essentials for
American Medicine,” National Physicians Committee.

Jour. M.S.M.S.

Michigan State Medical Society
Roster 1941

[An asterisk (*) preceding a name indicates active military service]

Beckett, M. B Allegan

Benning, H. M Allegan

Brown, Lewis Freeman Otsego

Brunson, Eugene T Ganges

Clough, William J Saugatuck

Dickinson, C. A Wayland

Dolfin, W. E Wayland

Flinn, C. C Allegan

Bunting, J. W Alpena

Burkholder, H. J Alpena

Carpenter, Clarence A Onaway

Constantine, A Harrisville

Hier, Edward A Alpena

Kessler, Harold Alpena

Altland, J. K Hastings

Cobb, Thomas H Woodland

Farwell, Byron E Delton

Finnie, R. G Hastings

Fisher, Gordon F Hastings

Alcorn, Kent

Allen, A, D

Andrews, F. T

Appel, S

Asline, J. N.

Austin, Justis

Baker, Charles H. . . .
Ballard, Sylvester L.

Ballard, W. R

Boulton, A. O

Brown, G. M

Connelly, C. J

Criswell, R, H

Dardas, M. J

DeWaele, Paul L. ...
Dickinson, John W.
Drummond, Fred . .

Dumond, V. H

Ely, Nina

Foster, L. Fernald..

Freel, John A

Gamble, W. G., Jr.
Gronemeyer, W. H. . .
Groomes, Charles . .

Gr os jean, J. C

Gunn, Robert

Gustin, J. W

Bay City

Bay City

Bay City

New York City

Essexville

. ...Tawas City

Bay City

Bay City

Bay City

Gladwin

Bay City

Bay City

Bay City

Bay City

Bay City

Oscoda

Kawkawlin

Bay City

Bay City

Bay City

Bay City

Bay City

Bay City

Bay City

Bay City

Standish

Bay City

Allen, J. U Benton Harbor

Allen, Robert Clarke St. Joseph

Anderson, H. B Watervliet

Bartlett, Wm. M Benton Harbor

Belsley, Frank K Benton Harbor

Bliesmer, A. F St. Joseph

Brown, F. W Watervleit

Brown, G. W Buchanan

Brown, Rolland J Benton Harbor

Burrell, H. J Benton Harbor

Cawthome, H. J Benton Harbor

Conybeare, R. C Benton Harbor

Crowell, Richard St. Joseph

Dunnington, R. N Benton Harbor

Eidson, Hazel Berrien Springs

*Ellett, W. C New York City

Emery, Clayton St. Joseph

Faber, Michael Benton Harbor

Friedman, Morris New Buffalo

Gillette, Clarence H Niles

Bailey, J. E Bronson

Beck, Perry C Bronson

Bien, W. J Coldwater

Chipman, E. M Quinsy

Culven Bert W Coldwater

Far, S. E Quincy

Fraser, R. J Coldwater

Allegan County

Hamelink, M. H Hamilton

Hudnutt, Orrin Dean Plainwell

Johnson, E. B Allegan

Johnson, H. H Martin

Mahan, James E Allegan

Medill, W. C Plainwell

Osmun, E. D Allegan

Ramseyer, Gladwin E Plainwell

Alpena County

Lister, George F. Hillman

Miller, A. R Harrisville

Moffat, Gordon B Rogers City

Monroe, Neil C Rogers City

O’Donnell, F. J. Alpena

Barry County

Gwinn, A. B Hastings

Harkness, Robert B Hastings

Keller, Guy C Hastings

Lathrop, Clarence P Hastings

Bay County

Hall, R. F

*Hagelshaw, G. L. . .

Hasty, Earl

Healy, Gaillard H. . .

Hess, C. L

Heuser, Harold H...
Horowitz, S. Franklin

Huckins, E. S

Hughes, E. C

Husted, F. Pitkin...

Jacoby, A. H

Jens, Otto

Jones, Jerry M

Kerr, William

Kessler, Mana

Kessler, S

Knobloch, Howard . .

Kowals, F. V

Lane, Milton

Laverty, L. F

Lerner, David

McEwan, J. H

MacPhail, Joseph . . .

Medvesky, M. J

Miller, Edwin C

Miller, Maurice C. . .
Mitton, O. W

Bay City

.... Carlisle, Pa.

Whittemore

Bay City

Bay City

Bay City

Bay City

Bay City

Bay City

Bay City

Bay City

Essexville

Bay City

Bay City

Bay City

Bay City

Bay City

Bay City

Bay City

Bay City

Au Gres

Bay City

Bay City

Bay City

Bay City

Auburn

. . . .East Tawas

Berrien County

Gunn, J. W

Hanna, P. G

Harper, Ina .........

Harrison, L. L

Hart, Russell T

Helkie, William L. . . .
Henderson, Fred . . .
Henderson, Robert . . .
Herring, Nathaniel A.

Hershey, Noel J

Higbee, Frank 0

Howard. R. B

Huff, H. D

Ingleright, Leon R. .

King, Frank, Jr

King, Frank A

Kling, H. C

Kok, Harry

Leva, John B_. _

Littlejohn, William . .

Watervleit

St. Joseph

.Benton Harbor

Niles

Niles

. . . .Three Oaks

Niles

Niles

Niles

Niles

. . . .Three Oaks
Benton Harbor

Niles

Niles

.Benton Harbor
Benton Harbor

Niles

Benton Harbor
Benton Harbor
Bridgman

Branch County

Gist, L. I Coldwater

Jarvis, Charles Grand Rapids

McLain. R. W Jackson

Meier, H. J Coldwater

Mooi, H. R Union City

Olmsted, Kenneth L Coldwater

Phillips, F. L Bronson

Rigterink, George H Hamilton

Roberts, M. S Fennville

Shepard, Lyle Otsego

*Stuch, Howard T

Carlisle Barracks, Penn.

Stuck, Olin H Otsego

Vaughan, W. R Plainwell

Van Der Kolk, Bert Hopkins

Walker, Robert J Saugatuck

Parmenter, E. S Alpena

Purdy, John W Lachine

Rutledge, S. H Rogers City

Secrist, Leo F Alpena

Wienczewski, Theophile Alpena

Lofdahl, Stewart Nashville

Lund, Chester A. E Middleville

McIntyre, K. S Hastings

Morris, Edgar T Nashville

Wedel, Herbert S Freeport

Moore, George W Bay City

Moore, Neal R Bay City

Mosier, D. J Bay City

Perkins, Roy C Bay City

Pearson, Stanley M Bay City

*Reutter, C. W Mt. Clemens

Riley, R, B Bay City

Scrafford, Royston Earl Bay City

'Shafer, H. C Bay City

Sherman, R. N Bay City

Slattery, M. R Bay City

Staley, Hugh Omer

Stinson, W. S Bay City

Stuart, Kenneth Bay City

Swantek, Charles M Bay City

*'Tarter, Clyde S Alexandria, La.

Timreck, Harold A Beaverton

Tupper, Virgil L Bay City

Urmston, Paul R Bay City

Warren, E. C Bay City

Wilcox, J. W Bay City

Wilson, Thomas G Bay City

Wittwer, E. A Bay City

Woodburne, H. L Bay City

Zaremba, Aloysius J Bay City

Ziliak, A. L Bay City

McDermott, J. J St. Joseph

Merritt, Charles W St. Joseph

Miller, E. A Berrien Springs

Mitchell, Carl A Benton Harbor

Moore, T. Scott Niles

Ozeran, Charles J Benton Harbor

Pritchard, H. M Niles

Reagan, Robert E Benton Harlxir

Richmond, D. M St. Joseph

Rosenberry, A. A Benton Harbor

Ruth, J. G Benton Harbor

Scholten, ■ Roger A Niles

Schram, John A St. Joseph

Smith, W. A Berrien Springs

Sowers, Bouton Benton Harbor

Strayer, J. C Buchanan

Thorup, Don W Benton Harbor

Waterson, Roy S Niles

Westervelt, H. O Benton Harbor

Yeomans, T. G St. Joseph

Schneider, H. A Coldwater

Schultz, Samuel Coldwater

*Scovill, H. A Fort Custer

Thomas, J. A Coldwater

Wade, R. L Coldwater

Walton, N. J Quincy

Weidner, H. R Coldwater

May, 1941

371

ROSTER FOR 1941

Abbott, Nelson Homer

Amos, Norman H Battle Creek

Baribeau, R. H Battle Creek

Barnhart, Samuel E Battle Creek

Becker, H. F Battle Creek

Beuker, Herman Marshall

Bonifer, Philip P Battle Creek

Brainard, C. W Battle Creek

Campbell, Alice jfUbion

Campbell, R. J Battle Creek

Church, Starr K Marshall

♦Chynoweth, W. R

Fort Sam Houston, Texas

Cooper, J. E Battle Creek

Curies, Grant R Battle Creek

Curry, Robert K Homer

Derickson. E. C Burlington

Dickson, A. R Battle Creek

Dodge, Warren M., Jr Battle Creek

Fahndrich, C. G Battle Creek

Finch, D. L Augusta

Forsyth, J. F Albion

Fraser, R. H Battle Creek

Funk, L. D Athens

Gething, Joseph W Battle Creek

Giddings, A. M Battle Creek

Gilfillan, Margery J Battle Creek

Godfrey, Willoughby L. ..Battle Creek

Gorsline, Clarence S'. Battle Creek

Graubner, F. L Marshall

Hafford, Alpheus T Albion

tHafford, Geo. C Albion

Hale, Claude E Marshall

Hansen, E. L Battle Creek

Hansen, Harvey C Battle Creek

Haughey. Wilfrid Battle Creek

Heald, C. W Battle Creek

Calhoun County

Henderson, Louis M Albion

Henderson, Phillip Albion

Herzer, Henry A Albion

Hills, C. R Battle Creek

Holes, Jesse J Battle Creek

;Holtom B. G Battle Creek

Howard, W. L Battle Creek

Hoyt, Aura A- Battle Creek

Hubly, James W Battle Creek

Humphrey, Archie Edward. .. .Marshall

Humphrey, Arthur A Battle Creek

Jesperson, Lydia Battle Creek

Johnston, S. Theron Battle Creek

Jones, T. K Marshall

Keagle, Leland R Battle Creek

Keeler, K. B Albion

Kellogg, Carrie Staines. .. .Battle Creek

Kellogg, John H Battle Creek

Kingsley, Paul C Battle Creek

Kinde, M. R Battle Creek

Kolvoord, Theodore Battle Creek

LaFrance, N. Francis .... Battle Creek

Landon, Charles C Battle Creek

Levy, Joseph Battle Creek

Lewis, W. B Battle Creek

Lowe, H. M Battle Creek

Lowe, Kenneth Battle Creek

Lowe, Stanley T Battle Creek

MacGregor, Archibald E. ..Battle Creek

McNair, L. N Albion

Meister, F. O Battle Creek

Melges, F. J Battle Creek

Mercer, C. M Battle Creek

Morrison, Donald B Tekonsha

Mortensen, M. A. ..Santa Monica, Cal.

Moshier, Bertha Battle Creek

Mullenmeister, H. F Battle Creek

Mustard, Russell Battle Creek

Patterson, Adonis Battle Creek

Riley, William H Battle Creek

Robbert, John Climax

Robins, Hugh Marshall

Rorick, Wilma Weeks Battle Creek

Rosenfeld, Joseph E Battle Creek

Roth, Paul Battle Creek

Royer, C. W Battle Creek

Selmon, Bertha L Battle Creek

Sharp, A. D Albion

Shipp, Leland P Battle Creek

Simpson, Robert S Battle Creek

Slagle, George W Battle Creek

Sleight, James D Battle Creek

Sleight, Raymond D Battle Creek

* Smith, T. C Canadian Army

Stadle, Wendell H Battle Creek

Stewart, Charles E Battle Creek

Stiefel, Richard Battle Creek

Tannenholz, Harold S Battle Creek

Taylor, Clifford B Albion

Thompson, Oliver E. ....Battle Creek

Upson, W. O. ...Battle Creek

Van Camp, Elijah Battle Creek

Vander Voort, W. V Battle Creek

Verity, Lloyd E Battle Creek

Vollmer, Maud J Moline, 111.

Walters, F. R Battle Creek

Walters, Royal W Battle Creek

Watson, Bernard Battle Creek

Wencke, Carl G Battle Creek

Whyte, Bruce Battle Creek

Winslow, Rollin C Battle Creek

Winslow, Sherwood B Battle Creek

Zindler, George A Battle Creek

*Zinn, Karl Rockford, III.

Adams, U. M Marcellus

Clary, R. I Dowagiac

Cunningham, E. M Cassopqlis

Hickman, John Dowagiac

Cass County

Kelsey, James H Cassopolis

Loupee, George Dowagiac

Loupee, S. L Dowagiac

Lyman, W. R Dowagiac

Newsome, Otis Cassopolis

Pierce, Kenneth C Dowagiac

Switzer, Lars M Cassopolis

Zwergel, E. H Cassopolis

Bandy, Festus Cecil.. Sault Ste. Marie

Birch, William Sault Ste. Marie

Blain, James G Sault Ste. Marie

Cook, Carl S Mackinac Island

Cornell, Eliphalet A. ..Sault Ste. Marie

Cowan, Donald Sault Ste. Marie

Gilfillan, E, O Sault Ste. Marie

Chippewa-Mackinac Counties

Hakala, L. J Sault Ste. Marie

Littlejohn, David ....Sault Ste. Marie
McBryde, Lyman M... Sault Ste. Marie

Mertaugh, W. F Sault Ste. Marie

Moloney, F. J Sault Ste. Marie

Montgomery, B. T Sault Ste. Marie

Rhmd, E. S St. Ignace

Vegors, Stanley H Sault Ste. Marie

Wallen, LeRoy J Sault Ste. Marie

Webster, E. H Sault Ste. Marie

Willison, C Sault Ste. Marie

Yale, I. V Sault Ste. Marie

Elliott, Bruce R Ovid

Foo, Charles T St. Johns

Frace, Guy H St. Johns

Hart, Dean W St. Johns

Clinton County

Ho, Thomas Y. ...

Luton, F. E

MacPherson, D. H...
McWilliams, W. B,

St. Johns

St. Johns

Fowler

Maple Rapids

Russell, Sherwood R St. Johns

Stoller, Paul Fowler

Wahl, George Edward St. Johns

Bachus, Arthur Powers

Bartley, George C. Escanaba

Benson, G. W Escanaba

Boyce, D. H Escanaba

Brenner, Ervin J Manistique

Carlton, A. J Escanaba

Chenoweth, Nancy R Escanaba

Clausen, C. H Gladstone

Defnet, Harry John Escanaba

Alexander, W. H Iron Mountain

Andersen, E. B Iron Mountain

Boyce, George H Iron Mountain

Browning, James L Iron Mountain

DeSalvo, Francis Iron Mountain

Fiedling, William Norway

tDeceased April 19, 1941.

372

Delta County

Diamond, J. A Gladstone

Forrester, Claud R. G Garden

Frenn, N. J Bark River

Fyvie, James Manistique

Groos, Harold Quinten Escanaba

Groos, Louis P Escanaba

Hult, Otto S Gladstone

Kitchen, A. S Escanaba

Lemire, William A Escanaba

Dickinson-Iron Counties

Fredrickson, Geron ....Iron Mountain

Gloss, Kenneth E Crystal Falls

*Haight, Harry M. . .San Diego, Calif.

Hamlin, Lloyd E Norway

Hayes, R. E Sagola

Huron, W. H Iron Mountain

Irvine, L. E Iron River

Lindquist, N. L Manistique

Long, Harry W Escanaba

Mclnerny, T Escanaba

Miller, Albert H Gladstone

Mitchell, James P Gladstone

Moll, G. W .Escanaba

Shaw, George A Manistique

Tonney, Fred O Escanaba

Walch, J. J Escanaba

Kerr, Loren, Stambaugh

Kofmehl, William J Stambaugh

Levine, D. A Iron River

Menzies. Clifford Iron Mountain

Place, Edwin H Iron Mountain

Retallack, R. C Iron River

Smith, Donald R Iron Mountain

White, Robert E Stambaugh

Jour. M.S.M.S.

ROSTER FOR 1941

Anderson, K. A. ... Harlingen, Texas

Arner, Fred Levi Bellvue

Brown, B. Philip Charlotte

Burdick, Austin F Grand Ledge

Carothers, Daniel J Charlotte

Engle, Paul Olivet

Hannah, H. W Charlotte

Hargrave, Don V Eaton Rapids

Huber, Charles D Charlotte

Adams, Chester Grand Blanc

Andrews, N. A. C Flushing

Anthony, George E Flint

Backus, G. R Flint

Bahlman, Gordon H Flint

Baird, James Flint

Bald, Frederick W Flint

Barbour, Fleming A Flint

Baske, Franklin W Flint

Bateman, L. G Flint

Benson, J. C Flint

Bernstein. Eli N Flint

Bishop, D. L Flint

Blakeley, A. C Flint

Bogart, Leon M Flint

Boles, William P Flint

Bonathan, A. T Flint

Bradley, Robert Flint

Brain, R. Gordon Flint

Branch, Hira E Flint

Brasie, D. R Flint

Briggs, Guy D Flint

Burkett, L. V Flint

Burnell, Max Flint

Burnside, Howard B Flint

Chambers, Myrton S Flint

Chandler, M. E Flint

Charters, John H Fenton

Childs, Lloyd H Flint

Clark, Clifford P Flint

Clift, M. William Flint

Cohen, Evelyn Flint

Colwell, C. W Flint

Connell, J. T Flint

Conover, G. V Flint

Conover, T. S Flint

Cook, Henry Flint

Covert, F. L Gaines

Credille, B. A Flint

Curry, George Flint

Curtin, J. H Flint

Del Zingro, N Davison

Dimond, E. G Flint

Dodds, F. E Flint

Drewyer, Glen Flint

Edgerton, A. C Clio

Eichhorn. Ernest Flint

Elliott, H. B Flint

Evers, J. W Flint

Farhat, M. M Flint

Finkelstein, T Flint

Flynn, S. T Flint

Foley, S. I Flint

Fuller, H. T Mt. Morris

Gelenger, S. M Flint

Gibson, Edward D Flint

Gleason, N. Arthur Flint

Goering, George R Flint

Anderson, Charles E Bessemer

Conley, W. C Ironwood

Crosby, Theodore S Ironwood

Gertz, M. A Ironwood

Gorrilla, A. C Ironwood

Gullickson, Miles Ironwood

Lieberthal, M. J Ironwood

Eaton County

Huyck, Stanhope Pier Sunfield

Imthun, Edgar F Grand Ledge

Lawther, John Ann Arbor

McLaughlin, C. L. D. . . . Vermontville

Moyer, H. A Charlotte

Myers, Albert W Potterville

Paine, E. Madison, Jr. ..Grand Ledge

Paine, E. M Grand Ledge

Quick, Phil H ' Olivet

Rickerd, Vinton J Charlotte

Genesee County

Golden, H. Maxwell Flint

Goodfellow, B Flint

Gome, S. S Flint

Grover, H. F Flint

Guile, Earle Flint

Guile, G. S Flint

Gundry, G. L Grand Blanc

Gutow, I Flint

Gntow, J. J Flint

*Hague, R. F Dearborn, Mich.

Halligan, Raymond S Flint

Handy, John W Flint

Harper, A. W Flint

Harper, Homer Flint

Harrison, L. D Saginaw

Hawkins, James E Flint

Hays, George A Flint

Hiscock, H. H Hint

Hoshal, V. L Flint

-Houston, James Swartz Creek

Hubbard, William B Flint

Johnson, F Flint

Kaufman, Lewis D Flint

Kirk, A. Dale Flint

Knapp, M. S Fenton

Kretchmar, A. H Flint

Kurtz, J. J Flint

Larribert, L. A Flint

Lavin, Kathryn R Flint

Leach, J. L Flint

Logan, G. W Flushing

MacDuff, R. B Flint

MacGregor, D. M Flint

MacGregor, R. W Flint

Macksood, Joseph Flint

Malfroid, B. W Flint

Marshall, William H Flint

Marsh, H. L Flint

Mason, Elta Flint

Matthewson, Guy C Flint

McArthur, A Flint

McArthur, R. H Qio

McGarry, Burton G Fenton

McGarry, R. A Flint

McGregor, James C Flint

McKenna, O. W Flint

Miller, Bryce Flushing

Miller, Edwin E Flint

Miner, Frederick B Flint

Moore, John W Flint

Moore, Kenneth B Flint

Morrish, Ray S Flint

Morrissey, V. H

Moiser, Edward C Otisville

Odle, Ira Flint

Olson, James A Flint

O’Neil, C. H Flint

Orr, J. Walter Flint

Gogebic County

Lieberthal, Paul Ironwood

Maloney, F. G. H Ironwood

Nezworski, H. T Ramsey

O’Brien, A. J Ironwood

Pinkerton, H. A Ironwood

Pinkerton, W. J Bessemer

Grand Traverse-Leelanau-Benzie Counties

Bolan, Ellis J Suttons Bay

Brownson, Jay J Kingsley

Brownson, Kneale Traverse City

Bushong, B. B Traverse City

Covey, E. L Honor

Ellis, Claude I Suttons Bay

Evans, E. E McAlester, Okla.

Gauntlett, J. W Traverse City

Goodrich, Dwight Traverse City

Grawn, F. A Traverse City

Hamilton, Earl E Traverse City

Holliday, George A Traverse City

Huene, Nevin Traverse City

Huston, Russell R Elk Rapids

Jerome, Jerome T Traverse City

Kitson, V. H Elk Rapids

Knapp, J. L Traverse City

Kyselka, H. B Traverse City

Lemen, Charles E Traverse City

Lossman, R. T Traverse City

Mu’-phy, Fred E Cedar

Nickels, M. M Traverse City

Osterlin, Mark Traverse City

Rennell, E. J Traverse City

Rinear, Edwin Traverse City

Sheets, R. Philip Traverse City

Sladek, E. F Traverse City

May, 1941

Sackett, C. S Charlotte

Sassaman, F. W Charlotte

Sevener, C. J Charlotte

Sevener, Lester G Charlotte

Sheets, A G Eaton Rapids

Stanka, Andrew George . . , Grand Ledge

Stimson, C. A Eaton Rapids

Stucky, George Charlotte

Van Ark, Bert Eaton Rapids

Wilensky, Thomas Eaton Rapids

Phillips, R. L Flint

Pfeifer, A. C Mt. Morris

Pratz, O. C Flint

Preston, Otto Flint

Probert, C. C Flint

Randall, H. E Flint

Reeder, Frank E Flint

Reichard, Orill Flint

Reid, Wells C Goodrich

Reynolds, A. J Flint

Rjce, E. D Flint

Richeson, V Flint

Roberts, Floyd A Flint

Rowley, James A Flint

Rundles, Walter Z Flint

Rynearson, W. J Fenton

Sandy, K. R Flint

Scavarda, Charles J Flint

Schiff, B. A Flint

Scott, R. D Flint

Shantz, L. O Flint

Sleeman, Blythe R Linden

Sheeran, Daniel H Flint

Shipman, Charles W Flint

Smith, D. C Flint

Smith, E. C Flint

Srnith, Maurice J Flint

Sniderman, Benjamin Flint

Snyder, Charles E Swartz Creek

Sorkin, Morris L Flint

Sorkin, S. S Flint

Spencer, J. A Flint

Steinman, F. H Flint

Stephenson, Robert A Flint

Stevenson, W. W Flint

Streat, R. W Flint

Stroup, C. K Flint

Sutherland, James K Flint

Sutton, George Flint

Sutton, M. R Flint

Thompson, Alvin Flint

Treat, D. L Flint

Trumble, G. W Flint

Vary, Edwin P Flint

Walcott, C. G Fenton

Walden, C. E Flint

Ward, Nell Flint

Ware, Frank A. Flint

Wark, D. R Flint

White, Herbert Flint

Williams, W. S Flint

Willoughby, G. L Flint

Willoughby, L. L Flint

Wills, T. N Flint

Winchester, Walter H Flint

Woughter, Harold W Flint

Wright, D. R Flint

Wright, G. R Montrose

Wyman, J. S Flint

Rees, Thomas R Ironwood

Reynolds, F. L Ironwood

Stevens, Charles E Bessemer

Tew, William Ellwood Bessemer

Tressel, H. A Wakefield

Urquhart, C. C Ironwood

Wacek, W. H Ironwood

Stone, Fordyce, H Beulah

Swanton, L Traverse City

Swartz, F. G Traverse City

Thacker, Fred R Frankfort

Thirlby, E. L Traverse City

Thompson, T. W Traverse City

Trautman, Frederick D Frankfort

Way, Lewis R Traverse City

W^itz, Harry Traverse City

Wi'lard, Wm. G Benzonia

Willoughby, Frances Lois. Traverse City

Zielke, I. H Traverse City

Zimmerman, J. G Traverse City

373

ROSTER FOR 1941

Aldrich, Alfred L Ithaca

Barstow, D. K St. Louis

Barstow, William E St. Louis

Baskerville, C. M Mt. Pleasant

Becker, Myron G Edmore

Budge, M. J Ithaca

Burch, L. J Mt. Pleasant

Burt, C. E Ithaca

Dale, Edward C Shepherd

Davis, L. L Mt. Pleasant

Drake, Wilkie M Breckenridge

Du Bois, C. F Alma

Alleger, W. E Pittsford

Bower, Charles T Hillsdale

Clobridge, C. E Allen

Day, Luther W Jonesville

Davis, L. A Montgomery

Fisk, Fred B Jonesville

Gray, J. P Hillsdale

Green, B. F Hillsdale

Hanke, George R Ransom

Abrams, James C Calumet

Acocks, J. R Houghton

Aldrich, A. B Houghton

Aldrich, Leonard Hancock

Bourland, Philip D Calumet

Brewington, George F Mohawk

Buckland, R. S Baraga

Burke, John Hubbell

Coffin, Leslie E Painesdale

Cooper, C. A Hancock

Gregg, W. T. S Calumet

Hillmer, R. E Beacon Hill

Caccamise, Joseph G Sebewaing

Gettel, Roy R Kinde

Henderson, J. Bates Pigeon

Herrington, Charles I Bad Axe

Albers, J. H East Lansing

Albert, Wilford D Leslie

Barnum, S. V Lansing

Barrett, C. D. Mason

Bartholomew, Henry S Lansing

Bauer, Theodore I Lansing

Behen, William C Lansing

Bellinger, E. G Lansing

Black, Charles E Lansing

Block, Bernita Lansing

Bradford, C. W Lansing

Breakey, Robert S Lansing

Brubaker, E Lansing

Brucker, Karl B Lansing

Bruegel, Oscar H East Lansing

Burhans, Robert Lansing

Cameron, W. J Lansing

Campbell, Archibald M Lansing

Carr, Earl I Lansing

Christian, _ L. G Lansing

Clark, William E Mason

Clinton, George Mason

Cook, R. J .Lansing

Cope, H. E Lansing

Corneliuson, Goldie Lansing

Corsaut. J. C Mason

Cross, Frank S Lansing

Darling, L. H Lansing

Davenport, C. S Lansing

Dean, Carleton Lansing

DeBold, Frederick F Lansing

DeVries, C. F Lansing

Doyle, Charles R Lansing

Doyle, C. P Lansing

Drolett, Fred J. Lansing

Drolett, Lawrence Lansing

Dunn, F. C Lansing

Dunn, F. M Lansing

Ellis, Bertha W Lansing

Ellis, C. W Lansing

Finch, Russell L Lansing

Fisher, D. W Lansing

Folkers, Leonard M East Lansing

Fosget, Wilbur W Lansing

Foust, E. H Lansing

French, Horace L Lansing

Galbraith, Dugald A Lansing

Gardner, C. B Lansing

Gibson, T. E Lansing

Goldner, R. E Lansing

Gratiot-Isabella-Clare Counties

Graham, B. J Alma

Hall, B, C Pompeii

Hammerberg, Kuno Clare

Harrigan, W. L Mt. Pleasant

Howe, Leslie A Breckenridge

Howell, Don M Alma

Johnson, P. R Mt. Pleasant

Lamb, E. T Alma

McArthur, Stewart C Mt. Pleasant

Oldham, E. S Breckenridge

Rondot, E. F Lake

Ingham County

Gunderson, G. O Lansing

Hagele, Marie A Lansing

Harris, Dean W Lansing

Harrold, J. F Lansing

Hart, L. C Lansing

Haynes, H. B Lansing

Haze, Harry A Lansing

Heckert, Frank B Lansing

Heckert, J. K Lansing

Hendren, Owen Williamston

Henry, L. L Lansing

Hermes, Ed. J Lansing

Himmelberger, R. J Lansing

Hodges, Kenneth P Lansing

Holland, Charles F East Lansing

Huggett, Clare C Lansing

Huntley, Fred M Lansing

Hurth, M. S Lansing

Hutchinson, W. G Lansing

Johnson, K. H Lansing

Jones, Francis A Lansing

Jones, Francis, Jr Lansing

Kalmbach, R. E Lansing

Keim, O. D Lansing

Kelly, Wm. H Lansing

Kent, Edith Hall Lansing

Kent, Herbert K Lansing

Kraft, L. C Leslie

Larrabee, E. E Williamston

LeDuc, Don M Lansing

Loree, Maurice C Lansing

Lucas, T. A Lansing

Ludlum, L. C Lansing

Martin, Wayne C. Lansing

McConnell, E. G Lansing

McCorvie, C. Ray East Lansing

McCoy, Earl M Grand Ledge

McCrumb, R. R Lansing

McElmurry, N. K Perry

McGillicuddy, Oliver B Lansing

McGillicuddy, R. J Lansing

McIntyre, J. E. Lansing

McNamara, William E Lansing

McPherson, E. G Champion

Mercer, Walter E East Lansing

Meyer, Hugh R Lansing

Miller, H. A Lansing

Mitchell, A .B Lansing

Morrow, R. J Lansing

Newitt, Arthur W. ...Tavares, Florida

Rottschafer, J. L Alma

Sanford, B. J Clare

Sarven, James D Middleton

Silvert, P. P Vestaburg

Slattery, F. G Clare

Town, F. R Mt. Pleasant

Waggoner, R. L St. Louis

Wilcox, R. A Alma

Wilson, Earl C Harrison

Wolfe, Kenneth P Alma

Wood, Cornelius B Oare

Martindale, E. A Hillsdale

McFarland, O. G North Adams

Miller, Harry C Hillsdale

Poppen, C. J Reading

Sandor, A. A Hillsdale

Sawyer, Walter Jonesville

Sterling, John S Jerome

Strom, A. W Hillsdale

Yeagley, J. L Waldron

Roche, A. C Calumet

Sarvela, H. L Hancock

Scott, William P Houghton

Sloan, Paul S Houghton

Smith, Charles R Houghton

Stern, Isadore D Houghton

Stewart, G. C Hancock

Stewart, J. C. B Painesdale

Tinetti, Ernest F Laurium

Ware, H. M Calumet

Willson, P. H Chassell

Winkler, Henry J L’Anse

Oakes, C. W Harbor Beach

Ritsema, John Sebewaing

Scheurer, C Pigeon

Thumme, Harrison F Sebewaing

Niles, B. D Lansing

Ochsner, P. J Lansing

O’Sullivan, Gertrude M2ison

Owen, A. E Lansing

Phillips, R. H Lansjng

Pinkham, R. A Lansing

Ponton, J Mason

Prall, H. J Lansing

Randall, O. M Lansing

Richards, F. D DeWitt

Roberts, D. W Lansing

Robson, Edmund J Lansing

Rozan, J. S Lansing

Rozan, M. M Lansing

Russell, Claude V. Lansing

Sander, John F Lansing

Sanford. Thomas M Lansing

Schnute, Louise F East Lansing

Seger, Ered L Lansing

Sichler, Harper G Lansing

Silverman, Irving E Lansing

Shaw, Milton Lansing

Smith, Anthony V Mason

Smith, H. M Lansing

Smith, Lillian R Lansing

Snell, D. M Lansing

Snyder, Le Moyne Lansing

Spencer, Perry Lansing

Steiner, A. A Lansing

Stiles, Erank Lansing

Strauss, P. C Lansing

Stringer, C. J Lansing

Tamblyn, F. W Lansing

Toothaker, Kenneth Lansing

Towne, Lawrence C Lansing

Troost, F. L Holt

Vander Slice, E. R Lansing

*Vander Zalm, T. P. ..Fort Knox, Ky.

Wadley, R Lansing

Warford, J. T Lansing

Webb, Roy O Okemos

Weinburgh, H. B Lansing

Welch, William H Lansing

*Wellman, John M Atlanta, Ga.

Wetzel, John O Lansing

Wheeler, Warren E Lansing

Wiley, Harold W Lansing

Willson, Howard S Lansing

Wilson, Harry A Lansing

Jour. M.S.M.S.

Hillsdale County

Hodge, C. L Reading

Hughes, Henry F Hillsdale

Joerin, Wm Camden

♦Johnson, C. E Camp Meade, Va.

*Kinzel, R. W Litchfield

Kline, Fred D Litchfield

MacNeal, J. A Hillsdale

Mattson, H. F Hillsdale

Houghton-Baraga-Keweenaw Counties

Janis, A. J Hancock

*Kadin, Maurice Rockford, 111.

King, William T Ahmeek

Kirton, Joseph R. W Calumet

LaBine, Alfred Houghton

Levin, Simon Houghton

MacQueen, Donald K Laurium

Manthei, W. A Lake Linden

Marshall, Frank F L’Anse

McClure, Robert James Calumet

Pleune, R. E Houghton

Quick, James B Laurium

Huron County

Herrington, Willet J Bad Axe

Holdship, Wm. B Ubly

Monroe, Duncan J Elkton

Morden, Charles B Bad Axe

374

ROSTER FOR 1941

Bird, William L Greenville

Bower, A. J Greenville

Bracey, L. E Sheridan

Bunce, E. P Trufant

Dunkin, Lloyd S Greenville

Ferguson, F. H Carson City

Fleming, J. C Pewamo

Fox, Harold M Portland

Fuller, Rudolphus W Crystal

Geib, O. P Carson City

Hansen, Carl M Stanton

Hansen, M. M Greenville

Haskell, Robert H Northville

Ahronheim, J. H Jackson

Alter, R. H .-...Jackson

Baker, G. M Parma

Balconi, Henry Jackson

Bartholic, F. W Grass Lake

Beckwith, S. A Jackson

Brown, H. A Jackson

Bullen, G. R Jackson

Chabut, H. M Jackson

Chivers, R. W Jackson

Clarke, C. S Jackson

Cochrane, Wayne A Jackson

Cooley, Randall M Jackson

Corley, C Jackson

Corley, Ennis Jackson

Cox, Ferdinand Jackson

Crowley, Edward D Jackson

Culver, Guy D Stockbridge

DeMay, C. E Jackson

Dengler, C. R Jackson

Edmonds, J. M Horton

Enders, W. H Jackson

Finton, Walter L Jackson

Finton, W. R ‘ Jackson

Foust, W. L Grass Lake

Gibson, F. J Jackson

Glover, H. G Jackson

Gordon, D. L .Jackson

Greenbaum, Harry Jackson

Hackett, T. E Jackson

Hanft, Cyril F Springport

Hanna, R. J Jackson

Hardie, G. O Jackson

Aach, Hugo Kalamazoo

Adams, R. U Kalamazoo

Alexander, C. A Kalamazoo

Andre, Harvey M. Kalamazoo

Andrews, Sherman Kalamazoo

Armstrong, Robert J Kalamazoo

Banner, Lawrence R Kalamazoo

Barnebee, J. Hosea Kalamazoo

Barnebee, J, W Kalamazoo

Barrett, F. Elizabeth Kalamazoo

Behan, Gerald W Galesburg

Bennet.t, Charles L Kalamazoo

♦Bennett, Keith Fort Custer

Berry, J. F Kalamazoo

Bodmer, H. C Kalamazoo

Borgman, Wallace Kalamazoo

Boys, C. E Kalamazoo

Brooks, Ervin D Kalamazoo

Burns, J. T Kalamazoo

Caldwell, George H Kalamazoo

Cobb, Horace R Kalamazoo

Cook, R. G Kalamazoo

*Crane, W. B Fort Custer

Crawford, Kenneth Kalamazoo

Dean, Ray Three Rivers

Den Bleyker, Walter Kalamazoo

DeWitt, L. H Kalamazoo

Dowd, B. J Kalamazoo

Doyle, F. M Kalamazoo

Ertell, William Francis Kalamazoo

Fast, R. B Kalamazoo

Fopeano, John V Kalamazoo

Fulkerson, C. B Kalamazoo

Fuller, R. T Kalamazoo

Fuller, Paul Kalamazoo

Gerstner, Louis Kalamazoo

Gilding, Joseph Vicksburg

Glenn, Audrey Kalamazoo

Grant, Frederick E Kalamazoo

Gregg, Sherman Kalamazoo

♦Adams, F. A San Diego, Calif.

Aitken, George T Grand Rapids

Alfenito, Felix S Grand Rapids

Allen, R. V Grand Rapids

Bachman, G. A Grand Rapids

Baert, George H Grand Rapids

Baker, Abel J Grand Rapids

Ballard, M. S Grand Rapids

May, 1941

lonia-Montcalm Counties

Hoffs, M. A Lake Odessa

Hollard, A. E Belding

Johns, Joseph J Ionia

Kelsey, L. E Lakeview

Kling, V. F Ionia

Lilly, Isaac S Stanton

Lintner, Roy C Ionia

Marsh, F. M Ionia

Marston, L. L Lakeview

Maynard, Herbert M Ionia

McCann, John J Ionia

Mintz, Morris J Greenville

Jackson County

Harris, Lester J Jackson

Hicks, Glenn C Jackson

Holst, John B Jackson

Hungerford, P. R Concord

Huntley, W. B Jackson

Hurley, H. L Jackson

Keefer, A. H Concord

Kudner, Don F Jackson

Kugler, J. C Jackson

Lake, William H Jackson

Lathrop, William W Jackson

♦LaVictoire, I. N. ..San Diego, Calif.

Leahy, E. O Jackson

Leonard, Clyde A Jackson

Lewis, E. F Jackson

Ludwick, J. E Jackson

McGarvey, W. E Jickson

McLaughlin, M. J Jackson

Meade, Wm. H East Lansing

Meads, J. B Jackson

Miller, J. L Jackson

Munro, C. D Jackson

Munro, James E Jackson

Murphy, B. M Jackson

Newton, R. E Jackson

Nichols, R. H Leslie

O’Meara, James J Jackson

Otis, Grant L Jackson

Payne, Andrew K Jackson

Peterson, E. S Jackson

Porter, H. W Jackson

Pray, Frank F Jackson

Kalamazoo County

Harter, Randolph S Schoolcraft

Heersma, H. S Kalamazoo

Hildreth, R. C Kalamazoo

Hodgman, Albert B Kalamazoo

Hoebeke, William G Kalamazoo

Holder, Charles Kalamazoo

Howard, W. H Galesburg

Hubbell, R. J Kalamazoo

Huyser, William C Kalamazoo

Ilgenfritz, F. M Kalamazoo

Irwin, William D Kalamazoo

Jackson, John B Kalamazoo

Jennings, W. O Kalamazoo

Kavanaugh, William R Kalamazoo

Kenzie, W. N Battle Creek

Klerk, W. J Kalamazoo

Koestner, Paul Kalamazoo

Kuhs, Milton L Kalamazoo

Lambert, R. H Kalamazoo

Lang, W. W Kalamazoo

Lavender, Howard Kalamazoo

Light, Richard Upjohn Kalamazoo

Light, S. Rudolph Kalamazoo

Littig, John Kalamazoo

MacGregor, J. R Kalamazoo

Malone, James G Kalamazoo

Marshall, Don Kalamazoo

McCarthy, J. S Kalamazoo

McIntyre, Charles H Kalamazoo

McNair, Rush Kalamazoo

Moe, Carl Rex Kalamazoo

Morter, Roy A Kalamazoo

♦Nell, E. R Fort Sill. Okla.

Nibbelink, Benjamin Kalamazoo

Okum, M. H Kalamazoo

Osborne, Charles E Vicksburg

Patmos, Martin Kalamazoo

Peelen, J. W Kalamazoo

Peelen, Matthew Kalamazoo

Perry, Clifton Kalamazoo

Kent County

Batts, Martin Grand Rapids

Beeman, Carl B Grand Rapids

Beeman, C. E Grand Rapids

Beets, W. Clarence Grand Rapids

Bell, Charles M Grand Rapids

Bettison, William L Grand Rapids

Billings, Elton P Grand Rapids

Blackburn, Henry M. ...Grand Rapids

Norris, William W Portland

Peabody, C. H Lake Odessa

Pankhurst, C. T Ionia,

Phelps, Everett L Clarksville

Slagh, Milton E Saranac

Socha, Edmund S Ionia

Swift, E. R Lakeview

VanDuzen, V. L Belding

VanLoo, J. A Belding

Weaver, Harry B Greenville

Whitten, R, R, Ionia

Willits, C. O Saranac

Pray, George R Jackson

Ransom, F. G. . . , Jackson

Riley, Philip Jackson

Roberts, Arthur J Jackson

Schepeler, Courtland W Brooklyn

Scheurer, Peter Arthur. .. .Manchester

Schmidt, T. E Jackson

Scott, John Jackson

Seybold, George A Jackson

Shaeffer, A. M Jackson

Sirhal, Alfred M Brooklyn

Smith, Dean W Jackson

Speck, John W Jackson

Spicer, W. E Jackson

Stewart, L. L Jackson

Sugar, Samuel Jackson

Susskind, M. V Jackson

Tate, Cecil E Jackson

Thayer, E. A Jackson

Thalner, L. F Jackson

Townsend, J. W. . . . Vandercook Lake

Tuthill, F. S Concord

Van Schoick, J. D Hanover

Van Schoick, Frank Jackson

Vivirski, Edward E Jackson

Wertenberger, M. D Jackson

Wholihan, John W. ..Michigan Center

Wickham, W. A Jackson

Wilson, E. D Cement City

Wilson, E. G Jackson

Wilson, N. D Jackson

Winter, G. E Jackson

Prentice, Hazel R Kalamazoo

Pullon, A. E Kalamazoo

Rickert, John A Allegan

Rigterink, G. H Kalamazoo

Rigterink, H. A Kalamazoo

Robson, Verna L Oshtemo Springs

Rockwell, A. H Kalamazoo

Rockwell, Donald C Kalamazoo

Ryan, F. C Kalamazoo

Sage, E. D Kalamazoo

Scholten, D. J Kalamazoo

Scholten, William Kalamazoo

Schrier, C. M Kalamazoo

Schrier, Paul Kalamazoo

Schrier, Thomas Comstock

Scott, William A Kalamazoo

Sears, H. A... Kalamazoo

Shackleton, William E Kalamazoo

Shepard, Benjamin A Kalamazoo

Shook, R. W Kalamazoo

Simpson, B. A Kalamazoo

Sofen, Morris B Kalamazoo

Southworth, M. N Schoolcraft

Stryker, Homer H Kalamazoo

Upjohn, E. Gifford Kalamazoo

Upjohn, L. N Kalamazoo

Van Ness, J. Howard Allegan

Van Urk, Thomas Kalamazoo

Ver Hage, Martin Kalamazoo

Volderauer, John C Kalamazoo

Wagar, Carl Kalamazoo

*Wagenaar, E. H

Fort Benj. Harrison, Indiana

Walker, Burt D Kalamazoo

Weirich. Richard Marcellus

Westcott, L. E Kalamazoo

Wilbur, E. P Kalamazoo

Youngs, A. S Kalamazoo

Youngs, C. A Kalamazoo

Bloxsom, P. W Grand Rapids

Bobczynski,_ Wilhelmina Grand Rapids

Boelkins, Richard C Grand Rapids

Boet, F. A Grand Rapids

♦Boet, John Alexandria, La.

Bond, George Lewis Grand Rapids

Bosch, L. C Grand Rapids

Brace, Fred Grand Rapids

375

ROSTER FOR 1941

Brayman, C. W Cedar Spring’s

Brennecke, F'ances E. ..Grand Rapids

Brink, Russel Grand Rapids

Brook, Jacob D Grandville

Brotherhood, J. S Grand Rapids

Buesing, O. R Grand Rapids

Bull, Frank L Sparta

Burleson, John S Grand Rapids

Burling, Wesley Grand Rapids

Butler, William J Grand Rapids

Byers, Earl J Grand Rapids

Campbell, Alexander McKenzie

Grand Rapids

Carpenter, Luther Clarendon

Grand Rapids

Chadwick, W. L Grand Rapids

Chamberlain, L. H Grand Rapids

Chandler, Donald Grand Rapids

Clapp, Henry W Grand Rapids

Claytor, R. W Grand Rapids

Collisi, H. S Grand Rapids

Colvin, W. G Grand Rapids

Corbus, Burton R. Grand Rapids

Cosgrove, Wm. J Grand Rapids

Crane, Charles V Grand Rapids

Crane, Harold D Grand Rapids

Cuncannan, M. E Grand Rapids

Currier, F. P Grand Rapids

Dales, Ernest W Grand Rapids

Damstra, H. J Grand Rapids

Davis, D. B Grand Rapids

Dean, Alfred W Grand Rapids

De Boer, Guy William ... Grand Rapids

Dell, E. E Sand Lake

DeMaagd, Gerald Rockford

DeMol, Richard J Grand Rapids

Denham, R. H Grand Rapids

De Free, Isla G Grand Rapids

De Free, Joseph Grand Rapids

DeVel, Leon Grand Rapids

De Vries, Daniel Grand Rapids

Dewar, M. M Grand Rapids

DeYoung, Thies Sparta

Dick, Mark W Grand Rapids

Dickstein, Bernard Grand Rapids

Dixon, Willis L Grand Rapids

Doran, Frank Grand Rapids

Droste, James C Grand Rapids

DuBois, William J Grand Rapids

Eaton, Robert M Grand Rapids

Eggleston, H. R Grand Rapids

*Farber, Charles E Detroit

Faust, L. W Grand Rapids

Ferguson, Lynn A Grand Rapids

Ferguson, Ward S Grand Rapids

Ferrand, L Rockford

Fitts, Ralph L. Grand Rapids

Flynn, J. D Grand Rapids

Foshee, J. C Grand Rapids

*Frantz, C. R Alexandria, La.

Fraiizen, Nils A Grand BLapids

*Freyling, Robert ...San Diego, Calif.

Fuller, E. H Grand Rapids

Gaikema, E. W Grand Rapids

Geenen, C. J Grand Rapids

Gilbert, R. H Grand Rapids

Gillett, O. H Grand Rapids

Grant, Lee O Grand Rapids

Graybiel, George F Caledonia

Griffith, L. S Grand Rapids

Haeck, Wm Grand Rapids

Hagerman, D. B Grand Rapids

Hammond, T. W Grand Rapids

Hayes, L. W Howard City

Heetderks, Dewey R Grand Rapids

Hegsted, Ralph B Grand Rapids

Henry, James, Jr Grand Rapids

Herrick, Ruth Grand Rapids

Hill, A. Morgan Grand Rapids

*Hilt, Lawrence M. ...Great Lakes, 111.

Holcomb, J. W Grand Rapids

Holdsworth, M. J Grand Rapids

Holkeboer, Henry D. ..Grand Rapids

Hollander, Stephen Grand Rapids

Hoogerhyde, Jack Grand Rapids

Hufford, A. R Grand Rapids

Hunderman, Edward. .. .Grand Rapids
Hutchinson, Robert J. . . . Grand Rapids

Hyland, W. A Grand Rapids

Ingersoll, C. F Grand Rapids

Irwin, Thomas C ...Grand Rapids

Jameson, Fred M Grand Rapids

Jaracz, W. J Grand Rapids

*Kelly, Robert E Detroit

Kemmer, Thomas R Grand Rapids

Kendall, Eugene L Grand Rapids

Klaus, C. D Grand Rapids

Kniskern, F. W Grand Rapids

Kooistra, Henry F Grand Rapids

Kremer, John Grand Rapids

Kreulen, H. J Grand Rapids

Kriekard, F. J Grand Rapids

Krupp, C. G Grand Rapids

Laird, Robert G Grand Rapids

Lamb, George F Grand Rapids

Lanning, N. E Grand Rapids

Lanting, D. B Grand Rapids

Le Roy, Simeon Grand Rapids

Lieffers, Harry Grand Rapids

Lyman, William D Grand Rapids

MacDonell, James A Lowell

*Marrin, M. M Fort Bliss, Texas

Marsh, J. F Grand Rapids

Maurits, Reuben Grand Rapids

McKenna, J. L Grand Rapids

McKinlay, L. M Grand Rapids

McRae, John H Grand Rapids

Meengs, Jacob Earl Grand Rapids

Mehney, Gayle H Grand Rapids

Miller, J. Duane Grand Rapids

Miller, John J Marne

Mitchell, H. C Grand Rapids

Mitchelh W. B Grand Rapids

Moen, Cornetta G Grand Rapids

Moleski, Leo Grand Rapids

*Moleski, Stanley L. ..Great Lakes, 111.

Moll, Arthur M Grand Rapids

Mollman, Arthur Grand Rapids

Moore, Vernor M Grand Rapids

Mulder, J. D Grand Rapids

Murphy, M. J Grand Rapids

Nelson, A. R Grand Rapids

Nesbitt, E. N Wyoming Park

Noordewier, Albert Grand Rapids

Northouse, Peter B Grandville

Northrup, William Grand Rapids

Nyland, Albertus Grand Rapids

Oliver, W. W Grand Rapids

Osborne, Howard Grand Rapids

Paalman, Russell J Grand Rapids

Patterson, P. Wilfred. .. .Grand Rapids

Pedden, j. R., Jr Grand Rapids

Phillips, J. W Grand Rapids

Pyle, Henry J Grand Rapids

Quigley, Ruth E Grand Rapids

Ralph, L. Paul Grand Rapids

Reed, Torrance Grand Rapids

Reus, William E Jamestown

Rjgterink, J. W Grand Rapids

Riley, G. L Grand BLapids

Roberts, Mortimer E Grand Rapids

Robinson, Harold C Grand Rapids

Rodgers, W. L Grand Rapids

Rogers, John R. Grand Rapids

Roth, Emil M Grand Rapids

Schermerhorn, L. J Grand Rapids

Schnoor, E. VV Grand Rapids

Schuitema, Donald Grand Rapids

Sculley, Ray E Grand Rapids

Seidel, Karl E Grand Rapids

Sevensma, Elisha S Grand Rapids

Sevey, L. E Grand Rapids

Shepard, B. H Lowell

Shellman, Millard \\' Grand Rapids

Slemons, C. C Grand Rapids

Smith, A. B Grand Rapids

Smith, Eerris N Grand Rapids

Smith, R. Earle Grand Rapids

Snapp, Carl F Grand Rapids

Snyder, Clarence Grand Rapids

Southwick, George H Grand Rapids

Steffensen, W. H. ...... . Grand Rapids

Stonehouse, G. G Grand Rapids

Stover, Virgil E Grand Rapids

Stuart, Gerhardus J Grand Rapids

Sugg, Cullen E Grand Rapids

Sus Strong, Carl A Grand Rapids

Swenson, H. C Grand Rapids

Ten Have, J Grand Rapids

Tesseine, A. J Grand Rapids

Teusink, J. H Cedar Springs

Thompson, Archibald B.. Grand lipids

Thompson, P. L Grand Rapids

Tidey, Marcus B Grand Rapids

Tiffany, Joseph C Grand Rapids

Torgersoii, William R. ...Grand Rapids
Van Belois, Harvard J. ..Grand Rapids

Van Bree, R. S Grand Rapids

VanDuine, H. J Byron Center

Vann, N. S Grand Rapids

Van Noord, Gelmer A. ..Grand Rapids
Van Solkema, Andrew ... Grand Rapids

Van Solkema, Arthur Grandville

Van Woerkom, Daniel ... Grand Rapids

Veldman, Harold E Grand Rapids

Veenboer, William H.... Grand Rapids

Venema, Jay R. Grand Rapids

Vis, William R Grand Rapids

Vyn, J. D Grand Rapids

Wamshuis, Frederick C.

Washington, D. C.

Webb, Rowland Grand Rapids

Webber, Jerome Grand Rapids

Webster, G. W Grand Rapids

Wedgewood, L. G Grandville

Wells, Merrill Grand Rapids

VV'enger, A. V Grand Rapids

Wenger, John N Coopers-ville

Westrate, Paul Grand Rapids

■*Whalen, John M. ..San Diego, Calif.

Whinery, Joseph B Grand Rapids

Willits, P. W Grand Rapids

Wilson, Wm. E Grand Rapids

Winter, Garrett E Grand Rapids

Woodbume, A. R Grand Rapids

Wright, John M Grand Rapids

Yegge, J. P Kent City

Best, Herbert M Lapeer

Bishop, G. Clare Almont

Burley, David H Almont

Chapin, Clarence D Columbiaville

Dorland, Clark Lapeer

Lapeer County

Hanna, Frederick R Lapeer

Johnson, Howard R Imlay City

McBride, J. R Lapeer

McLeod, K. W. A Lapeer

Merz, Henry G Lapeer

O’Brien, Daniel J Lapeer

Shrom, Howard K Imlay City

Thomas, J. Orville North Branch

Tinker, F. A Lapeer

Zemmer, H. B Lapeer

Abraham, A. O Hudson

Beebe, I. J Morenci

Blanchard, L. E Hudson

Bland, J. P Adrian

Blanden, Merwin R Tecumseh

‘Campbell, C. A Detroit

Case, C. W Onsted

Chase, Artemus W Adrian

Clark, A. D Adrian

Claxton, W. T Britton

Colbath, W. E Adrian

Hall, George C Adrian

Hammel, H. H Tecumseh

Hardy, P. B Tecumseh

376

Lenawee County

Heffron, Howard H Adrian

Helzerman, Ralph F Tecumseh

Hewes, A. B Adrian

Hornsby, W. B Clinton

Howland, F. A Adrian

Hulick. Peter V Adrian

Her, Harris D Clinton

Jewett, William E., Jr Adrian

Lamley, Arthur E Blissfield

Loveland, Horace H Tecumseh

MacKenzie, W. S Adrian

McGarvey, Maurice R Blissfield

*Marsh, R. G. B Alexandria, La.

‘Miller, Perry Ljmford Detroit

Morden, Esli T Adrian

Murawa, V. J Deerfield

Pasternacki, Arthur S Adrian

Patmos, Bernard Adrian

Peters, W. L Morenci

Raabe, E. C Morenci

Rawson, A. P Addison

Sp>alding, A. L Hudson

Stafford, Leo J Adrian

Tubbs, R. V Blissfield

VanDusen, C. A Blissfield

Whitney, O Adrian

Wood, A. C Adrian

Wynn, G. H Adrian

Jour. M.S.^f.S.

)

ROSTER FOR 1941

Brigham, Jeannette Howell

Burnett, Paul C Howell

Burt, K. L Howell

Cameron, Duncan A Brighton

Duffy, Ray M Pinckney

Finch, E. D Howell

Berghorst, John . . . Newberry

Bohn, Frank P Newberry

Campbell, Earl H Newberry

Gibson. Robert E Newberry

Allen, Leroy K Roseville

Bailey, R. St. Clair Shores

Banting, O. F Richmond

Barker, John G Center Line

Berry, Henry G Mt. Clemens

Bower, A. B Armada

Caster, E. Wilbur Mt. Clemens

Crawford, A. M Mt. Clemens

Croman, Joseph M., Jr. ..Mt. Clemens
Croman, Joseph M., Sr. ...Mt. Clemens

Deurloo, Henry W Romeo

Dudzinski, Edmund J. . . New Baltimore

Engels, J. A Richmond

Fluemer, Oswald Mt. Clemens

Hawley, R. E St. Clair Shores

Bryan, Kathryn M Manistee

Grant, C. L Manistee

Hansen, E. C Manistee

Konopa, John F Manistee

Bennett, Arthur K Marquette

Berry, Robert F Marquette

Bertucci, J. P Ishpeming

Blake, H. P ..Bergland

Bottum, Charles N Marquette

Burke, R. A Palmer

Casler, W. L Marquette

Conrad, George A Marquette

Cooperstock, M Marquette

Corcoran, W. A Ishpeming

Elzinga, E .R Marquette

Erickson, Arvid W Ishpeming

Fennig, F. A Marquette

Blanchette, Victor J Cluster

Livingston County

Gamble, Shelby O.... Howell

Glenn, Bernard H Fowlerville

Hayner, R. A Howell

Hendren, J. J Fowlerville

Hill, Harold C Howell

Huntington, H. G Howell

Luce County

Orr, A. C Newberry

Perry, Henry E Newberry

Purmort, William R., Jr Newberry

Rehn, Adolph T Newberry

Macomb County

Heine, A Mt. Clemens

Kane, William J Mt. Clemens

Lane, W. D Romeo

Lynch, Russell E Center Line

McGuire, A. J Utica

Moore, G. F Mt. Clemens

Mulligan, P. T Mt. Clemens

Reichman, Joseph J Mt. Clemens

Reitzel, R. H Mt. Clemens

Rivard, Charles L. . . . St. Claire Shores

Roth, G. E Armada

Rothman, A. M East Detroit

Ruedisueli, Clarence A Roseville

Salot, R. F Mt. Clemens

Manistee County

Lewis, Lee A Manistee

Lindquist, Paul Manistee

MacMullen, Harlen Manistee

Miller, E. B Manistee

Norconk, Ward H Bear Lake

Marquette-Alger Counties

Hanelin, H. A Marquette

Hartt, P. P Ishpeming

Hirwas, C. L Marquette

Hornbogen, D. P Marquette

Janes, R. Grant Marquette

Keskey, George I Marquette

Lambert, W. C Marquette

LeGolvan C Marquette

McCann, Neal J Ishpeming

McIntyre, D. R Negaunee

Mudge, W. A Negaunee

Nicholson, J. B Marquette

Niemi, O. I Marquette

Mason County

Goulet, L. J Ludington

Martin, W. S Ludington

Leslie, G. L Howell

Lojacono, Salvatore Howell

McDowell, Guy Marshall Howell

Mclndoe, R. Bruce Howell

Sigler, Hollis L ....Howell

Stephens, D. C Howell

Spinks, Robert Earl Newberry

*Surrell, M. A Alexandria, La.

Swanson, George F Newberry

Toms, Charles B Newberry

Scher, Joseph N Mt. Clemens

Seaman, John H New Haven

Sibrans, William A East Detroit

Siegfried, E. G New Haven

Smith, Milton C Mt. Clemens

Stone, Elizabeth A Romeo

Sturm, Fred A St. Clair Shores

Thompson, A. A Mt. Clemens

Ullrich, R. W Mt. Clemens

* Wellard, Henry G. .. .Alexandria, La.

Wilde, M. M Warren

Wiley, Bruce Utica

Wiley, Herbert H Utica

Wolfson, Victor H Mt. Clemens

Oakes, Ellery A Manistee

Ogilvie, G. D Manistee

Quinn, Henry M Copemish

Ramsdell, Homer A Manistee

Whitley, Alec Bear Lake

Pauli, Frank O Marquette

Picotte, Wilfrid S Ishpeming

Robbins, Nelson J Negaunee

Schutz, W. J Munising

Stevenson, Theodore D Ishpeming

Swinton, A. L Marquette

Talso, Jacob Ishpeming

Van Riper, Paul Champion

Waldie, George M Ishpeming

Westcott, Royal Morgan Heights

Wickstrom, George Munising

Witters, Josef E Gwinn

Paukstis, Charles Ludington

Bruggema, Jacob Evart

Campbell, James B Big Rapids

Chess, Leo F Reed City

Franklin, Benjamin L Remus

Grieve, Glenn Big Rapids

DeWane, F. J Menominee

Flanagan, Clarence B Menominee

*Heidenreich, John R

San Antonio, Texas

Jones, William S Menominee

Ballmer, Robert S Midland

Gay, Harold Howard Midland

Grewe, N. C Midland

High, C. V., Jr Midland

Howe, Irvin M Midland

Mecosta-Osceola-Lake Counties

Hall, Clifton Big Rapids

Kilmer, Paul B Reed City

Klein, J. Paul Reed City

MacIntyre, Donald Big Rapids

McGrath, V. J Reed City

Menominee County

Kaye, J. T Menominee

Kerwell, K. C Stephenson

Mason, Stephen C Menominee

Montgomery, Robert .... Hermansville
Peterson, A. R Daggett

Midland County

Linsenmann, Karl W Midland

MacCallum, Charles Midland

Meisel, Edward H Midland

Pike, Melvin H Midland

Rice, Robert E Midland

Phillips, R. W Remus

Treynor, Thomas P Big Rapids

Yeo, Gordon H Big Rapids

Sawbridge, Edward Stephenson

Scully, John C Menominee

Sethney, Henry T Menominee

Towey, J. W Powers

Schriack, Ray Midland

Sherk, J. H Midland

Sjolander, Gust Midland

Towsley, W. D Midland

Von Haitinger, Kalmon S Midland

May, 1941

377

ROSTER FOR 1941

Acker, William F Monroe

Ames, Florence Monroe

Balk, A. C Monroe

Barker, Vincent L ....Monroe

Blakey, L. C Monroe

Bond, W. W Monroe

Cooper, E. M Rockwood

Denman, D. C Monroe

Dusseau, S. V Erie

Ewing, R. T Monroe

Fieldhouse, B. J Ida

Flanders, J._ P Monroe

Gelhaus, William J Monroe

Anderson A. T Muskegon

August, R. V. Muskegon Heights

Bartlett, F. H Muskegon

Beers, Charles Holton

Benedict, A. L Muskegon

Bloom, C. J Muskegon

Boyd, D. R Muskegon

Bradshaw, _ Park S Muskegon

Chapin, William S... Muskegon Heights

Clo'sz, H. F Muskegon

Cohan, Sol G Muskegon

Colignon, C. M Muskegon

Collier, C. C Whitehall

D’Alcorn, Ernest Muskegon

Dasler, A. F Muskegon Heights

Derezinski, Clement F Muskegon

Diskin, Frank Muskegon

Douglas, Robert Muskegon

Durham, C. T Muskegon

Dykhuisen, Harold D Muskegon

Eckerman, C. T Muskegon

Fillingham, Enid Muskegon

Flejschman, C. B Muskegon

Fleishman, Norman Muskegon

Foss, Edward O Muskegon

Garber, F. W., Jr Muskegon

Monroe County

Golinvaux, C. J Monroe

♦Goodman, Louis. .San Antonio, Texas

Heffernan, John F Carleton

Humphrey, J. A Monroe

Hunter, M. A Monroe

Johnson, A. Esther Monroe

Landon, Herbert W Monroe

Long. Edgar C Monroe

Long, Sara Monroe

McDonald, T. A Monroe

McGeoch, R. W Monroe

McMillin, J. H Monroe

Muskegon County

Garland, J. O Muskegon

Gillard, James Muskegon

Go'ltz, Martha H Montague

Griffith, Robert M Muskegon

Hagen, Wm. A Muskegon

Hannum, F. W Muskegon

Harrington, A. F Muskegon

Harrington, R. J Muskegon

Hartwell, S. W Muskegon

Henevela, John Muskegon

Holly, Leland E Muskegon

Holmes, Roy H Muskegon

Jackson, S. A Muskegon

Kane, Thomas J Muskegon

Keilin, Marie Muskegon

Kerr, H. J ..Muskegon

Kniskem, E. L Muskegon

LaCore, O. M Muskegon Heights

Lange, E. W Muskegon

Lauretti, Emil Muskegon

Laurin, V. Samuel Muskegon

LeFevre, George L Muskegon

*LeFevre, Louis Sparta, Wis,

LeFevre, William M Muskegon

Loomis, John L Muskegon

Loughery, H. B Muskegon

Morely, Louise Monroe

Parmelee, O. E Lambertville

Pinkus, H. K Monroe

Reisig, A. H Monroe

Sanger, Emerson J Monroe

Siffer, J. J Monroe

Smith, William A Petersburg

Stolpestad, C. T Monroe

Tomlinson, Ledyard New Port

Wag;ar, Spencer Rockwood

Williams, Robert J Monroe

Williamson, George W Dundee

Mandeville, C. B Muskegon

Medema, Paul E Muskegon

Meengs, M. B Muskegon Heights

Miller, Philip L Muskegon

Morford, F. N Muskegon

Morse, Bertram W Whitehall

Mulligan, A. W Muskegon

Oden, Constantine L Muskegon

Olson, R. G Muskegon Heights

Petkus, Antonie ...Muskegon Heights

Pettis, Emmett Muskegon

Powers, Lunette Muskegon

Price, Leonard Muskegon

Pyle, H. J Muskegon

Risk, R. A Muskegon

Risk, Robert D Muskegon

Scholle, N. W Muskegon

Spoor, A. A Muskegon

Stone, Maxwell E Muskegon

Swartout, W. C Muskegon

Teifer, Charles A Muskegon

Thieme, S. W Ravenna

Thornton. E. S Muskegon

Wilke, C. A Montague

Wilson, P. S Muskegon

Barnum, W. H Fremont

Deur, T. R Grant

Edwards, Albert Fremont

Geerlings, Lambert Fremont

Newaygo County

Geerlings, Lewis J Fremont

Geerlings, Willis Fremont

♦Gordon, B. F Fort Custer

Lettinga, D Grant

Moore, H. R Newaygo

Saxen, Raymond White Cloud

Stryker, O. D Fremont

Tompsett, Arthur C Hesperia

North Central Counties

(Otsego-Montmorency-Crawford-Oscoda-Roscommon-Ogemaw-Gladwin-Kalkaska Counties)

Beeby, R. J West Branch

Clippert, C. G Grayling

Coulter, Keith Douglas Gladwin

Crandell, C. H West Branch

Drescher, George A Lewiston

Egle, Joseph L Gaylord

Harris, Levi A Gaylord

Hendricks, Henning V Kalkaska

Inman, John Kalkaska

Jardine, Hugh M West Branch

Keyport, C. R Grayling

Lanting, Helen E Gladwin

Lanting, Roelof Gladwin

LaPorte, Lawrence A Gladwin

Martzowka, M. A Roscommon

McDowell, Douglas B West Branch

McKillop, G. L Gaylord

Palm, John Pruddenville

Peckham, Richard C Gaylord

Sargent, Leland E Kalkaska

Skinner, Edward F Gaylord

Stealy, Stanley Grayling

Thompson, Sue H West Branch

Northern Michigan

(Antrim-Charlevoix-Cheboygan-Emmet Counties)

Beuker, Bernard East Jordan

Blum, Benjamin B Petoskey

Burns, Dean C Petoskey

Chapman, Wallace M Charlevoix

Chapmam Willis Earle Cheboygan

Conkle, Guy C Boyne City

Conti, Joseph Petoskey

Conway, William S Petoskey

Duffie, Don Hastings .... Central Lake
Frank, Gilbert E Harbor Springs

Giffords, Mark Charlevoix

Larson, Walter E Levering

Lashmet, Floyd H Petoskey

Lilga, Harris V Petoskey

Litzenburger, A. F Boyne City

Maksim, George Petoskey

Mast, W. H Petoskey

Mayne, Frederick C Cheboygan

McCarroll, James C Cheboygan

McGune, William Stanley .... Petoskey

Palmer, Russell St. James

Parks, W. H Petoskey

Reed, Wilbur F Cheboygan

Rodgers, John Bellaire

Saltonstall, Gilbert B Charlevoix

Stringham, J. R Cheboygan

Van Dellen, Jerrian .Ellsworth

Winter, Joseph A Mackinaw City

Abbott, V. C Pontiac

Arnkoff, Harry Royal Oak

Aschenbrenner,_ Z. R Farmington

Baker, Frederick A Pontiac

Baker, Robert H Pontiac

Barker, Howard, B Pontiac

Bauer, Ernest W Hazel Park

Beattie, W. G Ferndale

Beck, Otto O Birmingham

Benning, C. H Royal Oak

Berg, Richard H .Oxford

Borland, Alexander Pontiac

Boucher, R. E Royal Oak

Bradley, Everett L Pontiac

Burke, Chauncey G Pontiac

Burt, F. J Holly

Butler, Samuel A Pontiac

378

Oakland County

Christie, J. W Pontiac

Church, J. E Pontiac

Clark, Charles D. Royal Oak

Cobb, Leon F Pontiac

Cooper, Robert J Pontiac

Cottrell, Martha S Novi

Couchman, Boyd Royal Oak

Crissman, Harold C Ferndale

Cudney, Ethan B Pontiac

Dahlgren, Carl Keego Harbor

Darling, C. G., Jr Pontiac

Dobski, Edwin J Pontiac

Ekelund, Clifford T Pontiac

Farnham, Lucius Aug;ustine .... Pontiac

*Faulconer, Albert Rochester

Ferris, Ralph G. .._ Brimingham

Fitzpatrick, Francis Pontiac

Flick, John R Royal Oak

Foust, Earl W Hazel Park

Fox, John W Pontiac

Furlong, Harold A Lansing

Gaensbauer, Ferdinand Pontiac

Gariepy, Bernard F Royal Oak

Gatley, C. R Pontjac

Gatley, L. Warren Pontiac

Gehinger, Norman F Pontiac

Geib, Ormond D Rochester

Gerls, Frank B Pontiac

Gill, Matthew J Detroit

Gordon, J. H Birmingham

Grant, William A Milford

Green, William M Pontiac

Hackett, Daniel Joseph Pontiac

Halsted, Lee H Farmington

Jour. M.S.M.S.

ROSTER FOR 1941

Hammer, Carl W Oxford

Hammonds, E. E Birmingham

Harris, Landy E Pontiac

Harvey, Campbell Pontiac

Hassberger, J. B Birmingham

Hathaway, Clarence L. ...Lake Orion

Hathaway, William Rochester

Henry, Colonel R Ferndale

Hensley, C. B Lake Orion

Howlett, E. V Pontiac

Hoyt, D. F Pontiac

♦Hubert, John R Pontiac

Huffman, M. R Milford

Hume, T. W. K Auburn Heights

Hurst, Daniel D Pleasant Ridge

Jones, Morrell M Pontiac

Kemp, Felix J Pontiac

Kemp, W. Lloyd Birmingham

Kukuk, M. R Pontiac

Lambie, John S Pontiac

Lambert, Alvin Gerald Ferndale

Larson, B. T Pontiac

Lass, E. H Oxford

Lawler, C. F Birmingham

Lewis, Sol M Ferndale

Little, J. W Pontiac

Llewellyn, M. B Pontiac

Lockwood, C. E Holly

Macinnis, Francis Pontiac

Mackenzie, O. R Walled Lake

Margrave, Edmund D Royal Oak

Markley, John Martin Pontiac

Day, Clinton Hart

Flint, Charles Hart

Hay ton, A. R Shelby

Heard, William Pentwater

Bender, Jesse L Mass

Evans, Edwin J Ontonagon

Hogue, H. B Ewen

Beemink, E. H Grand Haven

Bloemendaal, D. C Zeeland

Bloemendal, W. B Grand Haven

Boone, Cornelius E Zeeland

Bos, G. D Holland

Clark, N. H Holland

DeVries, H. C Holland

De Witt, S. L Grand Haven

DeYoung, Fred Spring Lake

Hager, Ralph Hudsonville

Harms, H. P Holland

Ackerman, Gerald L Saginaw

Anderson, W. K Saginaw

Bagley, U. S Saginaw

Bagshaw, David E Saginaw

Berberovich, T. F Saginaw

Bishop, H. M Saginaw

Brender, Fred P Frankenmuth

Brock, W. H Saginaw

Busch, Frank J Saginaw

Butler, M. G Saginaw

Button, A. C Saginaw

Cady, F. J Sag^inaw

Calomeni, Anthony D Saginaw

Cameron, Allen K Saginaw

Campbell, L. A Saginaw

Catizone, R. J Merrill

Chisena, Peter R Saginaw

Clark, Wilbert B Saginaw,

Claytor, Archer A Saginaw

Cortopassi, Andre Saginaw

Cortopassi, V. E. . . . Saginaw

Cory, C. W Saginaw

Curts, James Saginaw

Durman, Donald C Saginaw

Ely, C. W Saginaw

Ernst, Arthur Randolph Saginaw

Eymer, Esther Saginaw

Fleschner, Thomas E Birch Run

Freeman, Frederick W Saginaw

Gage, David P Saginaw

Galsterer, Edwin C Saginaw

Goman, Louis D Saginaw

Grigg, Arthur Saginaw

Grigg, Arthur P Saginaw

Hand, Eugene Saginaw

Blanchard, E. W Deckerville

Cochran, Lewis E Peck

Gift, W. A Marlette

Hart, R. K Crosweli

May, 1941

Mason, Robert J. . . .

McConkie, J. P

McEvoy, Francis J. ..

McNeill, H. H

Meinke, Herman A. . ,

Mercer, Frank A

Miller, Raymond E. .

Mitchell, B. M

Monroe, J. D

Mooney, C. A.

Neafie, Charles A

Needle, Francis

Newcomb, Arnold B..

Norup, John

Ohlmacher, A. P

Olsen, Richard E. . . .

Osgood, S. W

Pauli, Theodore H. . . .
Pelletier, Charles J. . .

Pool, H. H

Porritt, Ross J

Ports, Preston W. . . .
Prevette, Isaac C. . . .
Quamme, Roy K. . .
Raynale, George P. . .

Reid, Fred T

Riker, Aaron D

Roehm, Harold R. . . .
Rooks, Wendell H....

Rowley, Laurie G

Russell, Vincent P. . .
St. John, Harold A.

. . .Birmingham
. . .Birmingham

Royal Oak

Pontiac

, . . . Hazel Park

Pontiac

Clarkston

Pontiac

Pontiac

Ferndale

Pontiac

Pontiac

Berkley

Berkley

. . . .Royal Oaic

Pontiac

Clawson

Pontiac

. . . . Hazel Park

Pontiac

Pontiac

. . . Farmington

Pontiac

Pontiac

. . . Birmingham

Clawson

Pontiac

. . .Birmingham

Pontiac

Drayton Plains
. . .Royal Oak
Pontiac

Oceana County

Lemke, Walter M Shelby

Munger, L. P Hart

Nicholson, John H Hart

Ontonagon County

McHugh, Frank W Ontonagon

Rubinfeld, S. H Ontonagon

Shale, R. J Ontonagon

Ottawa County

Irvin, Harry C Holland

Kemme, Gerrit Zeeland

Kools, William Clarence .... Holland

Leenhouts, Abraham Holland

Long, C. E Grand Haven

Nichols, Rudolph H Holland

Nykamp, Russell Zeeland

Presley, William J Grand Haven

Rypkema, Willard M Grand Haven

Stickley, A. E Coopersville

Saginaw County

Harvie, L. C Saginaw

Helmkamp, Herbert C Saginaw

Hester, E. G Saginaw

Hill, Victor L Saginaw

Hohn, Fred J Saginaw

*Imerman, Harold M

San Antonio, Texas

Jaenichen, R Saginaw

James, J. W Saginaw

Jiroch, R. S Saginaw

Jordan, Leo A Saginaw

Keller, S. S Saginaw

Kemp, J. M Saginaw

Kempton, R. M Saginaw

Kirchgeorg, Clemens G. . .Frankenmuth

Kleekamp, H. G Saginaw

Knott, Harriet A Saginaw

Ling, Ernest M Hernlock

Lohr, O. W Saginaw

Ix)ngstreet, Martha L Saginaw

Luger, F. E Saginaw

Lurie, Robert Saginaw

MacKinnon, Edwin D Saginaw

MacMeekin, James Ware Saginaw

Markey, Jos. P Saginaw

Martzowka, William P Saginaw

Maurer, John A Saginaw

Maurer, J. G Saginaw

Mayne, Harold Saginaw

McClinton, N. F Saginaw

McGregor, R Saginaw

McKinney, Alex. R Saginaw

McLandress, Joshua A Saginaw

Meyer, Henry J Saginaw

Moon, A. R. Saginaw

Sanilac County

Koch, D Brown City

Learmont, H. H Crosweli

McGunegle, K. T Sandusky

Norgaard, Hal V Marlette

Schneider, Alexander Pontiac

Schoenfeld, John B Birmingham

Schuneman, Howard Ferndale

Seaborn, A, J Royal Oak

SheflSeld, L. C Pontiac

Sherman, George A Lansing

Sibley, H. A Pontiac

Simpson, E. K Pontiac

Smith, Carleton A Pontiac

Smith, Donald S Pontiac

Spears, M. L Pontiac

Spencer, Lloyd H Royal Oak

Spoehr, Eugene L Ferndale

Spohn, Earl W Royal Oak

Stahl, Harold F Oxford

Stanley, William F Ferndale

Starker, Clarence T Pontiac

Steinberg, Norman Royal Oak

Stolpman, A. K Birmingham

Sutton, Palmer E Royal Oak

Terry, Stuart Pontiac

Tuck, Raymond G Pontiac

Uloth, Milton J Ortonville

Vatz, Jack A Pontiac

Wagley, P. V Pontiac

Wagner, Ruth E Royal Oak

Watson, Thomas Y Birmingham

Weinberger, Herbert Pontiac

Wentz, A. E Birmingham

Williams, H. W Pontiac

Yoh, Harry B Pontiac

Young, Arthur R Pontiac

Reetz, Fred A Shelby

Robinson, W. Gordon Hart

Wood, Merle G Hart

Strong, W. F Ontonagon

Whiteshield, C. F Trout Creek

Tempas, Henry W Coopersville

Ten Have, Ralph Grand Haven

Timmerman, E. C Coopersville

Van Appledom, Chester J Holland

Ver Duin, J Grand Haven

Van Der Berg, E Holland

Van der Velde, O Holland

Wells, Kenneth Spring Lake

Westrate, William Holland

Wiersma, Silas C Hudsonville

Winter, John K Holland

Winter, William G Holland

Morris, Keith M Saginaw

Murphy, Albert P Saginaw

Murray, Charles R Saginaw

Novy, F. O Saginaw

O’Reilly, William J Saginaw

Ostrander, Frank W Freeland

Phillips, Homer A Saginaw

Pietz, Frederick Saginaw

Pillsbury, Edward A Frankenmuth

Poole, Frank A Saginaw

Potvin, Clifford D Saginaw

Richards, Ned R Saginaw

Richter, Harry J Saginaw

Ryan, M. D Saginaw

Ryan, R. S Saginaw

Sample, J. T Saginaw

Sargent, D. V Saginaw

Schaiberger, Elmer Saginaw

Sheldon, S. A Saginaw

Skowronski, Casimer A Saginaw

Slack, W. K Saginaw

Stander, A. C Saginaw

Stewart, George Saginaw

Stiller, A. F Saginaw

Stolz, Harold F Saginaw

Thomas, Dale Saginaw

Thompson, A. B Saginaw

Tiedke, G. E Saginaw

Toshach, C. E Saginaw

♦Wallace, Herbert C

Alexandria, Louisiana

Wheeler, Dorothy Saginaw

Wilson, H. Roy Saginaw

Yntema, S Saginaw

Robertson, Colin G Sandusky

Seager, M. Cole Brown City

Tweedie, G. Evans Sandusky

Tweedie, S. Martin Sandusky

Webster, John C Marlette

379

ROSTER FOR 1941

1

Alexander, Reuben G Laingsburg

Arnold, Alfred L., Jr Owosso

Arnold, A. L., Sr Owosso

Backe, John C Corunna

fBates, L. F Durand

*Brandel, J. D

Fort Sam Houston, Texas

Brown, Richard J Owosso

Camper, T. E Corunna

Carney, Edward J Durand

Armsbury, A. B Marine City

Atkinson, J. M Port Huron

Attridge, J. A Port Huron

Banting, K. C Port Huron

Battley, J. C. Sinclair ... .Port Huron

Beck, Frank K Port Huron

Biggar, R. J Port Huron

Borden, C. L Yale

Boughner, W. H Algonac

Bovee, M. E Port Huron

Brush, Howard O Port Huron

Burke, Ralph M Port Huron

Burley, Jacob H Port Huron

Callery, A. L Port Huron

Campbell, R. H St. Clair

Carey, Lewis M Detroit

Carney, F. V St. Clair

Clyne, B. C Yale

Berg, Lawrence A Centerville

Brunson, A. E Colon

Buell, Martin Sturgis

Dodrill, F. D Three Rivers

Fiegel, S. A Sturgis

Fortner, F. J Three Rivers

Hoekman, Aben Constantine

Barbour, Harry A Mayville

Bates, George Kingston

Berman, Harry Millington

Cook, Raymond Akron

Dickerson, Willard W Caro

Dixon, Robert L Caro

Donahue, H. Theron Cass City

*Fisher, Robert E. San Antonio, Texas
Flett, Richard O Millington

Boothby, Carl F Lawrence

Boothby, F. M Lawrence

Bope, William P Decatur

French, Merle R Paw Paw

Gano, Avison Bangor

Giddings, Ralph R Bloomingdale

Hall, E. J Hartford

Hasty, W. A Gobles

Hoyt, W. F Paw Paw

Agate, George H Ann Arboi

Alexander, John Ann Arbor

Badgley, C. E Ann Arbor

Barker, Paul Ann Arbor

Barnwell, John B Ann Arbor

Barr, A. S Ann Arbor

Barss, Harold D Ypsilanti

Bassow, Paul H Ann Arbor

Baugh, R. H Milan

Beebe, Hugh M Ann Arbor

Bell, Margaret Ann Arbor

Belser, Walter Ann Arbor

Bethel, Frank Hartstuff . . . .Ann Arbor

*Blair, Thomas H Fort Custer

Brace, William M Ann Arbor

Breakey, J. F Ann Arbor

Breakey, James R Ypsilanti

Britton, H. B Ypsilanti

Brown, Phillip Ypsilanti

Bruce, James D Ann Arbor

Bulmer, Dan J Ann Arbor

Buscaglia. C. J Ypsilanti

Camp, Carl Dudley Ann Arbor

Campbell, Darrell A Ann Arbor

Catron, Lloyd F Akron, Ohio

Clements, Glenn T Ann Arbor

Coiler, Frederick A Ann Arbor

Conn, Jerome W Ann Arbor

Cooper, Ralph Ruehl Ann Arbor

Coxon, Alfred W Ann Arbor

Cummings, H. H Ann Arbor

Curtis, Arthur C Ann Arbor

tDeceased April 5, 1941

Shiawassee County

Cramer, George L. G Owosso

Crane, C. A Corunna

Fillinger, W. B Ovid

Greene, I. W Owosso

Hume, Arthur M Owosso

Hume, Harold A Owosso

Janci, Julius Owosso

Kaufman, H. J Owosso

Linden, V. E Durand

McKnight, E. R Owosso

St. Clair County

Cooper, T. H Port Huron

DeGurse, T. E Marine City^

Derek, W. P Marysville'

Falk, Edwin Carl Algonac

Fraser, Robert C Port Huron

Heavenrich, Theodore F. ..Port Huron

Holcomb, R. J Marine City

Kesl, George Matthew. ... Port Huron

Le Galley, K. B Port Huron

Dicker, R. R Port Huron

Ludwig, F. E Port Huron

McCue, Christopher Goodells

MaePherson, C. A St. Clair

Martin, C. S Port Huron

McColl, D. J Port Huron

McColl, Neil J Port Huron

Meredith, E. W Port Huron

Patterson, D. Webster .... Port Huron

St. Joseph County

Holm, Arvid G Three Rivers

Kane, David M Sturgis

Miller, C. G Sturgis

Parrish, Marion F Sturgis

Pennington, H. C White Pigeon

Raisch, Fred J White Pigeon

Reed, Fred R Three Rivers

Tuscola County

Fox, Denton B Caro

Gugino, Frank James Reese

Hoffman, T. E Vassar

Howlett, R. R Caro

Johnson, O. G Mayville

Kaven, G. H Unionville

MacRae, L. D Gagetown

Merrill, Elmer H Caro

Morris, Frank L Cass City

Van Buren County

Iseman, Joseph W Paw Paw

Itzen, J. F South Haven

Kingma, J. G Decatur

Laird, Emma Paw Paw

Lowe, Edwin G Bangor

Maxwell, J. Charles Paw Paw

McNabb, A. A Lawrence

Murphy, Norman D Bangor

Penoyar, C. L South Haven

Washtenaw County

Davis, Fenimore E Ann Arbor

DeAlvarez-Skinner, Russell R. . . .

De Jong, Russell Ann Arbor

DeRyke, Gilbert R Ann Arbor

De Tar, John S Milan

Dingman, Reed O Ann Arbor

Donaldson, S. W Ann Arbor

*Dowman, Charles E. .. .Anniston, Ala.

Dtinstone, H. C Ypsilanti

Emerson, Herbert W Ann Arbor

Everett, Meldon Ann Arbor

Failing, Joseph H Ann Arbor

Farrior, J. Brown Ann Arbor

Farris, Jack Ann Arbor

Field, Henry, Jr. ... Ann Arbor

Folsome, Clair Edwin

Tenafly, New Jersey

Forsythe, Warren E Ann Arbor

Fralick, F. Bruce Ann Arbor

Freyberg, Richard H Ann Arbor

Frye, Carl H Ann Arbor

Furstenberg, Albert C Ann Arbor

Ganzhorn, Edwin Ann Arbor

Gardiner, Sprague Baltimore, Md.

Gates, John L Ann Arbor

Gates, Neil A Ann Arbor

Gehring; Harold W Ann Arbor

German,’ Jas. W Ypsilanti

Gordon, William G Ann Arbor

Green, Mervin E Ann Arbor

Guide, Andros Chelsea

Hagerman, George W Ann Arbor

Haight, Cameron Ann Arbor

Hammond, W. W Plymouth

Parker, W. T Owosso

Pochert, R. C Owosso

Richards, C. J Durand

Shepherd, W. F Owosso

Slagh, E. M Elsie

Soule, Glenn T Henderson

Watts, Fred A Owosso

Weinkauf, W. F Corunna

Wilcox, Anna L Owosso

Wilcox, C. M Owosso

Pollock, Donald A Yale

Reynolds, Annie E Port Huron

Ryerson, W. W Port Huron

Searles, Karl F Capac

Schaefer, W. A, Port Huron

Sites, E. C Port Huron

Smith, George Reginald . . Port Huron

Thomas, C. F Port Huron

Treadgold, Douglas Port Huron

Vroman, M. E Port Huron

Waltz, J. F Capac

Ware, John R. Port Huron

Wass, Henry C. St. Clair

Waters, George Port Huron

Wellman, Joseph E Port Huron

Wight, William G Yale

Witter, Gordon L Port Huron

Zemmer. A. L Port Huron

Rice, John W Sturgis

Sheldon, J. P Sturgis

Slote, L. K Constantine

Springer, R. A Centerville

Sweetland, G. J Constantine

Zimont, R. D Constantine

Petrie, William Caro

Rundell, Annie Stevens Vassar

Ruskin, D. B Caro

Savage, Lloyd L Caro

Spohn, U. G Fairgrove

Starmann, Bernard Cass City

Swanson, E. C Vassar

*Vail, Harry F

Alexandria, Louisiana

Von Renner, Otto Vassar

Sayre, Phillip P South Haven

Spalding, R. W Gobles

Steele, Arthur H Paw Paw

TenHouten, Charles Paw Paw

*Terwilliger, Edwin

San Antonio, Texas

Williams, F. N Hartford

Young, William R Lawton

Hannum, M. R Milan

Harris, Bradley M Ypsilanti

Haynes, Harley A Ann Arbor

Helper, Morton Ann Arbor

Healey, Claire E Ann Arbor

Henry, L. Dell Ann Arbor

Himler, Leonard E ...Ann Arbor

Hodges, Fred J Ann Arbor

Howard, S. C Ann Arbor

Howes, Homer A Ann Arbor

Jackson, Howard C Ann Arbor

Jimenez, Buenaventura Ann Arbor

Johnson, Lester J Ann Arbor

Johnson, Vincent C Ann Arbor

Johnston, Franklin D Ann Arbor

Jordan, Paul H Ann Arbor

Kahn, Edgar A Ann Arbor

Keller, Arthur P Ann Arbor

Kemper, J. W Ann Arbor

Kleinschmidt, Earl E Chicago, 111.

Kleinschmidt, Gladys Chicago, 111.

Klingman, Theophil Ann Arbor

Knoll, Leo Ann Arbor

Kretzschmar, Norman R. Ann Arbor

La Fever, Sidney L Ann Arbor

Lamberson, Frank A Detroit

Lampe, Isadore Ann Arbor

Law, John L Ann Arbor

Lichty, Dorman E Ann Arbor

List, Carl F Ann Arbor

Lowell, Vivion E Ypsilanti

Lynn, Harold P Ypsilanti

Maddock, Walter G Ann Arbor

380

Jour. M.S.M.S.

ROSTER FOR 1941

Malcolm, Karl D Ann Arbor

Marshall, Mark Ann Arbor

Martin, Donald W Ypsilanti

Maxwell, James H Ann Arbor

McCotter, Rollo E Ann Arbor

McEachem, Thomas H Ann Arbor

McKhann, Chas F Ann Arbor

Metzger, Ida Ypsilanti

Miller, Harold Saline

Miller, Norman F Ann Arbor

Moore, Donald F Ypsilanti

i Muehlig, Geo. F Ann Arbor

Myers, Dean W Ann Arbor

Nesbit, Reed M Ann Arbor

Newburgh, L. H Ann Arbor

Oliphant, L. W Ann Arbor

Palmer, Alger A Chelsea

Patterson, Ralph M Ann Arbor

Peet, Max Ann Arbor

Peterson, Reuben Duxbury, Mass.

Pillsbury, Charles B Ypsilanti

Pollard, H. M Ann Arbor

*Power, Frank H Ft. Jackson, S. C.

Price, Helen F Ann Arbor

!

I Aaron, Charles D Detroit

Abrams, Harry M Detroit

Abramson, Max Detroit

j Adams, James Robert Dearborn

, Adelson, Sidney L Detroit

i Adler, Leopold Detroit

I Adler, Sidney Detroit

Agins, Jacob Detroit

Agnelly, Edward J Detroit

Agnew, George H Detroit

Albrecht, Herman F Detroit

Aldrich, Napier S Detroit

Alford, E. S Belleville

Allen, Norman M Detroit

Alles, Russell W Detroit

Allison, Frank B Detroit

Allison, Herbert C Detroit

Altman, Raphael Detroit

Altshuler, Ira M Detroit

Altshuler, Samuel S Detroit

Amberg, Emil Detroit

Ames, C. C Detroit

Amolsch. Arthur L Detroit

Amos, Thomas G Detroit

Anderson, Bruce Detroit

Anderson, Gordon H Detroit

Anderson, J. O Detroit

Anderson, Walter L Detroit

Anderson, Walter T Detroit

Andries, Joseph H Detroit

Andries, Raymond C Detroit

Ankley, J. W Detroit

Anslow, Robert E Detroit

Appel, Phillip R Detroit

*Appelman, H. B Fort Custer

Arehart, Burke W Detroit

Armstrong, Arthur G Detroit

Armstrong, Oscar S Detroit

Arnold, Effie Detroit

Aronstam, Noah E Detroit

Ascher, Meyer S Detroit

Ashe, Stilson R Detroit

Ashley, L. Byron Detroit

Ashton, F. B Highland Park

Asselin, J. L Detroit

Asselin, Regis F Detroit

Atchison, Russell M Northville

Athay, Roland M Detroit

Atler, Lawrence R Detroit

August, Harry E Detroit

Babcock, Kenneth B Detroit

Babcock, Myra E Detroit

Babcock, W. L. Detroit

Babcock, W. W Detroit

Bach, Walter F Detroit

Bachman, Morris E Detroit

Bacon, Vinton A Detroit

Baeff, Michael A Detroit

Baer, Raymond B Detroit

Bagley, Harry E Dearborn

Bailey, Carl C Detroit

Bailey, Don_ A Detroit

Bailey, Louis J Detroit

Baker, Qarence Detroit

Bakst, Joseph Detroit

Balcersla, Matthew A Detroit

Ballard, Charles S Detroit

Balser, Charles W Detroit

Baltz, James I Detroit

Barker, F. Marion Grosse Point

Barnett, Saul E. Detroit

Barrett, Wyman D Detroit

Bartemier, Leo H Detroit

Barton, J. R Detroit

Bauer, A. Robert Detroit

Bauer, Benedict J Detroit

May, 1941

Prout, Gordon J Saline

*Rague, Paul O Fort Custer

Ransom, Henry Ann Arbor

Raphael, Theophile Ann Arbor

Ratliff, Rigdon K Ann Arbor

Reynolds, Stephen Ann Arbor

Riecker, Herman H Ann Arbor

Riggs, Harold W Ann Arbor

Robb, David N Ypsilanti

Ross, C. Howard Ann Arbor

Sacks, Wilma Ann Arbor

Sames, Albert A Ann Arbor

Schumacker, W. E Ann Arbor

Seime, Reuben I Whitmore Lake

Sheldon, John M Ann Arbor

Sibbald, Malcolm L Chelsea

Sink, Emory W Ann Arbor

Slasor, Wm. J Ann Arbor

Smalley, Marianna Ann Arbor

Smith, Kenneth M Ann Arbor

Smyth, Charley J Ann Arbor

Snow, Glenadine Ypsilanti

Solis, Jeanne C Ann Arbor

Soller, M. E Ypsilanti

Wayne County

Bauer, Lester Eugene Detroit

Baumer, Moe Detroit

Baumgarten, Elden C Detroit

Beach, Watson Detroit

Beam, A. Duane Detroit

Beaton, Colin Detroit

Beattie, Robert Detroit

Beatty, S. M Detroit

Beaver, Donald C Detroit

Beck, Eva F Eloise

Becker, Abraham Detroit

Becker, Joseph William Detroit

Becklein, C. L Detroit

Beckwitt, M. C Eloise

Bedell, A Detroit

Beer, Jos ...Detroit

Beeuwkes, L. E Dearborn

Begle, Howell L Detroit

Behn, Claud W Detroit

Beigler, Sydney K Detroit

Beitman, Max R Detroit

Belanger, Ernest E River Rouge

Belanger, Henry Detroit

Belknap, Warren F Detroit

Bell, J. Kenner Detroit

Bell, William M Detroit

Bennett, Germany E Detroit

Bennett, Harry B Detroit

Bennett, Zina B Detroit

Benson, C. D Detroit

Benson, Davis A Detroit

Bentley, Neil I Detroit

Beresh, Louis Detroit

Berge, Clarence A Detroit

Berke, Sydney S Detroit

Berkowitz, William E Detroit

Berman, Harry S Detroit

Berman, Lawrence Detroit

Berman, Robert Detroit

Berman, Sidney .'Detroit

Berman, Sidney ..Detroit

Bernard, Walter G Detroit

Bernbaum, Bernard Detroit

Bernstein, Albert E Detroit

Bernstein, Samuel S Detroit

Berry, Joseph E Detroit

Besancon, J. H Detroit

Best, T. H. Edward Detroit

Bicknell, Frank B Detroit

Biddle, Andrew P Detroit

Birch, John R Detroit

Birkelo, Carl C Detroit

Bittker, I. Irving Detroit

Black, Perry S Detroit

Blaess, Marvin J Detroit

Blain, Alex W., Jr Detroit

Blain, Jas. H., Jr Detroit

Blair, K. E Detroit

Blanchard, Fred N Detroit

Blashill, James B Detroit

Bleier, Alfred Detroit

Bleier, Joseph. Detroit

Bloch, Abraham Detroit

Blodgett, William E Detroit

Blodgett, Wm. H Detroit

Bloom, Arthur R Detroit

Bloomer, Earl Dearborn

Blumenthal, Franz I Detroit

Boccaccio, John Detroit

Boccia, James J Detroit

Boddie, Arthur W Detroit

Boehm, John D Detroit

Boell, Arthur F Detroit

Bogusz, Ladislaus Detroit

Bohn, Stephen Detroit

Boileau, Thornton I Detroit

Steiner, L. G

Sundwall, John

Teed, Reed Wallace

Thieme, E. Thurston

Towsley, Harry A

Vander Slice, David

Van Zwaluwenburg, Benj.

Waggoner, R. W

Waldron, Alexander M.. . .

Wallace, J. B

Wanstrom, Ruth C. ..^...
Washburne, Charles L. ...

Weller, Carl V

Wessinger, J. A

Wile, Udo J

Williamson, F. B

Wilson, Frank N

Wisdom, Inez

Woods, J. J

Work, Walter P

Worth, Melissa H

Wright, Walter J

Wylie, William C.

Yoder, O. R

.Ann Arbor
.Ann Arbor
.Ann Arbor
.Ann Arbor
.Ann Arbor
.Ann Arbor
.Ann Arlxir
.Ann Arbor
.Ann Arbor

Saline

.Ann Arbor
.Ann Arbor
.Ann Arbor
.Ann Arbor
.Ann Arbor
. . .Ypsilanti
.Ann Arbor
. Ann Arbor
. . .Ypsilanti
.Ann Arbor
. . .Ypsilanti
. . .Ypsilanti

Dexter

. . .Ypsilanti

Boland, J. Rolland Detroit

Boles, A. E Detroit

Bovill, Edwin G - Detroit

Bowers, Leo J Detroit

Bowman, Frank E Detroit

Boyd, John H Detroit

Bracken, Andrew H Dearborn

Bradshaw, William H Detroit

Braitman, Louis Detroit

Braley, Alson E ....Detroit

Braley, William N Detroit

*Brancheau, L. T.

Camp Beauregard, La.

Brand, Benjamin Detroit

Brando, Russell G Detroit

Brandt, Edward L Detroit

Braun, Lionel Detroit

Breitenbecher, Edward R Detroit

Brengle, Deane R Detroit

Breon, Guy L Detroit

Briegel, Walter A Detroit

Brines, O. A Detroit

Bringard, Elmer L Detroit

Brisbois, Harold J Plymouth

Brodersen, Harvey S River Rouge

Bromme, William Detroit

Brooks, A. L Detroit

Brooks, Clark D Detroit

Brooks, Charles W Detroit

Brosius, William L Detroit

Brough, Glen A Detroit

Brown, A. O Detroit

Brown, Carlton F Detroit

Brown, Harvey F Detroit

Brown, Henry S Detroit

Brown, John R Detroit

Brown, Stanley H Detroit

Brown, Thomas A Detroit

Brownell, Paul G Detroit

Brunk, Andrew S Detroit

Brunk, C. F Detroit

Brunke, Bruno B Detroit

Bryce, John D Detroit

Buchanan, W. Paul Detroit

Buchner, Harold W Detroit

Budson, Daniel Detroit

Buell, Charles E., Jr Detroit

Buesser, Frederick G Detroit

Buffer, H. L Detroit

Bullock, Earl S Detroit

Burgess, Charles M Detroit

Burgess, Jay M Detroit

Burns, Robert T Detroit

Burnstine, Julius Y Detroit

Burnstine, Perry P Detroit

Burr, George C Detroit

Burr, H. Leonard Detroit

Burton, D. T Detroit

*Bush, Glendon J Rantoul, Iff.

Bush, Lowell M Detroit

Buss, John A Detroit

Butler, Harry J Detroit

Butler, L. H Detroit

Butler, 'Volney N Detroit

Butterworth, Herman K. ..Lincoln Park

Buttram, Edward J Detroit

Byers, Dudley W Detroit

Byington, Gamer M Detroit

Cadieux, Henry W Detroit

Caldwell, J. Ewart Detroit

Calkins, H. N Detroit

Callaghan, T. T Detroit

Campau, George H Detroit

Campbell, Don M Detroit

Campbell, Duncan Detroit

Campbell, Duncan A Detroit

381

ROSTER FOR 1941

Campbell, John A Detroit

Campbell, Malcolm D Detroit

Campbell, Mary B Detroit

Candler, Clarence L Detroit

Canter, Allie E Detroit

Canter, Gayle E Detroit

Caplan, Leslie Detroit

Caraway, James E Wayne

Carey, Benjamin W Detroit

Carey, Cornelius Detroit

Carleton, L. H Detroit

Carmichael, E. K Detroit

Carnes, Harry Detroit

Carp, Joseph Detroit

Carpenter, C. H Detroit

Carpenter, C. J Detroit

Carr, J. G Detroit

Carroll, Lona B Detroit

Carson, Herman J Detroit

Carstens, Henry R Detroit

Carter, John M Detroit

Carter L. F Detroit

Cassidy, William J Detroit

Castrop, C. W Dearborn

Cathcart, Edward Detroit

Catherwood, Albert E Detroit

Caughey, Edgar H Detroit

*Cavell, Roscoe Eloise

Cetlinski, C. A Hamtramck

Chalat, Jacob H Detroit

Chall, Henry G Detroit

Chance, J. H Detroit

Chapman, Aaron L Detroit

Chapman, Everett L Detroit

Chapnick, H. A Detroit

Chase, Clyde H. . Detroit

Chatel, Arthur N Detroit

Chene, George C Detroit

Chenik, Ferdinand Detroit

Chester, W. B Detroit

Chesluk, H. M Detroit

Chipman, W. A Detroit

Chittenden, George E Detroit

Chittick, William R. ..San Diego, Calif.

Chostner, G. C Detroit

Christensen, C. A Dearborn

Christopoulos, D. G Detroit

Chrouch, Laurence A Detroit

Ciprian, Joseph E Detroit

Clark, Benjamin W Detroit

Clark, C. M Detroit

Clark, Donald V Detroit

Clark, George E Detroit

Clark, Harold E Detroit

Clark, Harry G Detroit

Clark, Harry L Detroit

Clark, Raymond L Detroit

Clarke, Emilie Arnold Detroit

Clarke, George L Detroit

*Clarke, Niles A.

Camp Beauregard, La.

Clarke, Norman E Detroit

Cleage, Louis J Detroit

Clifford, Charles H Detroit

Clifford, John E Detroit

Clippert, J. C Grosse He

Coan, Glenn L Wyandotte

Coates, Carl Amos Dearborn

Cobane, John H Detroit

Cochrane, Edgar G Detroit

Cohn, Daniel E Detroit

Cohoe, Don A Detroit

Cole, Fred H Detroit

Cole, James E Detroit

Cole, Wyman C. C Detroit

Coleman, Margarete W Detroit

Coleman, Wm. G Detroit

Coll, Howard R Detroit

Collins, Edmund F Detroit

Colyer, Raymond G Detrojt

Connelly, Basil L Detroit

Connelly, Richard C Detroit

Connolly, Frank Detroit

Connolly, John P Detroit

Connor, Guy L Detroit

Connors, J. J Detroit

Conrad, E. R Detroit

Cooksey, Warren B Detroit

Cooley, Thomas B Detroit

Coolidge, Maria Belle .. Grosse Pt. Park

Cooper, E. L Detroit

Cooper, James B Detroit

Corbeille, Catherine Detroit

Corbett, John J Detroit

Coseglia, Robert P Detroit

Costello, Russell T Detroit

Cothran, Robert M Detroit

Cotruro, L. D Detroit

Cotton, S. O Detroit

Coucke, Henry O Detroit

Coulter, William J Detroit

Cowan, Wilfred Detroit

Cowen, Leon B Detroit

Cowen, Robert L Detroit

Coyne, Douglas Ruthven Detroit

Craig, Henry R Eloise

Crawford, Albert S Detroit

Cree, Walter J Detroit

Crews, Thomas H Detroit

Croll, L. J Detroit

Cross, Harold E Detroit

Crossen, Henry F Detroit

Croushore, J. E * Detroit

Cruikshank, Alexander Detroit

Curry, F. S Detroit

Curtis, Frank E Detroit

Cushing, Russell G Detroit

Cushman, H. P Detroit

*Dana, Harold M Fort Custer

Danforth, J. C Detroit

Danforth, Mortimer E Detroit

♦Daniels, L. E Fort Custer

Darling, Milton A Detroit

Darpin, Peter H Detroit

Davidow, David M Detroit

Davidson, Harry O Detroit

Davies, Thomas S Detroit

Davies, Windsor S Detroit

Davis, Egbert F Detroit

Davis, James E Detroit

♦Davis, Lindon Lee Fort Custer

Dawson, F. E Detroit

Dawson, W. _A Detroit

Defever, Cyril R Detroit

Defnet, William A Detroit

*DeGroat, Albert Fort Custer

DeHoratiis, Joseph Detroit

Demaray, John F Detroit

Dempster, James H Detroit

DeNike, A. James Detroit

Denis, George M Detroit

Denison, Louis L Detroit

Derby, Arthur P Detroit

Derleth, Paul E Detroit

DeTomasi, Rome Detroit

Dibble, Harry F Detroit

Dickman, Harry M Detroit

Dickson, B. R Detroit

Diebel, Nelson W Detroit

Diebel, William H Detroit

Dietzel, H. O Detroit

Dill, Hugh L Detroit

Dill, J. Lewis Detroit

♦DiLoreto, Panfilo Camillo . Carlisle, Pa.

Dittmer, Edwin Detroit

Dixon, Fred W Detroit

Dixon, Ray S Detroit

Dodds, John C Detroit

Dodenhoff, C. F Detroit

Doerr, Louis E Detroit

Domzalski, C. A Detroit

Donald, Douglas Detroit

Donald, William M Detroit

Donovan, John D Detroit

Dorsey, John M Detroit

Doty, Chester A Detroit

Doub, Howard P Detroit

Douglas, Bruce H Detroit

Douglas, Clair L Detroit

Dovitz. Benjamin W Detroit

Dow, Roy E Detroit

Dowdle, Edward Detroit

Dowling, Harvey E , Detroit

Dowling, Pearl Christie Detroit

Downer, Ira G Detroit

Doyle, George H Detroit

Drake, James J Detroit

Drews, Robert S Detroit

Drolshagen, E. A Detroit

Droock, Victor Detroit

Droste, Arnold T Dearborn

Drummond, Donald L Detroit

Dubin, Joseph J Dearborn

Dubnove, Aaron Detroit

DuBois, Paul W Detroit

Dubpernell, Karl Detroit

Dubpernell, Martin S Detroit

Ducey, Edward F Detroit

Duffy, Edward A Detroit

Dundas, E. M Detroit

Dunlap, Henry A Detroit

Dunn, Cornelius E Detroit

Durocher, Edmund J Ecorse

Durocher, Normand E Detroit

Dutchess, Charles E Detroit

Dwaihy, Paul Detroit

Dwyer, F. J Wyandotte

Dwyer, Francis Detroit

Dysarz, T. T< Detroit

Dziuba, John F Detroit

Fades, Charles C Detroit

Eakins, Frederick J Dearborn

Eder, Joseph R Detroit

Eder, Samuel J Detroit

Edgar, Russell G Detroit

Edwards, J. W Detroit

Eisman, Clarence H Detroit

Elliott, William G Detroit

Ellis, Seth W Detroit

Elvidge, Robert J Detroit

Emmert, Herman C Detroit

Engel, Earl H Wyandotte

Engel, John B Detroit

Ensign, Dwight C Detroit

Ensing, Osborn Detroit

Epstein, S. G Detroit

Erickson, Milton H Eloise

Erkfitz, Arthur W Detroit

Erman, Joseph M Detroit

Eschbach, Joseph W Dear^m

Estabrook, Bert U Detroit

Ettinger, Clayton J Detroit

Evans, Leland S Detroit

Evans, William A., Jr Detroit

Falick, Mordecai Louis Detroit

Falk, Ira E , Detroit

Fandrich, Theodore Detroit

Farbman, Aaron A Detroit

Fauman, David H Detroit

Faunce, Sherman P Detroit

Fay, George E Detroit

Felcyn, W. George.- Detroit

Feldstein, Martin Z ...Detroit

Fellman, Abraham R Detroit

Fenton, E. H Detroit

Fenton, Meryl M Detroit

Fenton, Russell F Detroit

Fenton, Stanley C Detroit

Ferrera, Louis V Detroit

Fettig, Carl A Detroit

Fine, Edward Detroit

Fischer, Frederick J Detroit

Fisher, O. O Detroit

Fisher, R. L Detroit

Fitzgerald, E. W Detroit

Fitzgerald, James M Detroit

Flaherty, H. J Detroit

Flaherty, N. W Detroit

Flaherty, S. A Detroit

Fleming, L. N Detroit

Flora, William R Detroit

Flower, J. A Detroit

Foley, Hugh S Dearborn

Font, Anthony J Detroit

Foote, James A Lincoln Park

Ford, F. A. Detroit

Ford, George A Detroit

Ford, Sylvester Detroit

Ford, Walter D ....Detroit

Forrester, Alex V Detroit

Forsythe, John R Detroit

Foster, E. Bruce Detroit

Foster, Linus J Detroit

Foster, Owen C Detroit

Foster, William L Detroit

Foster, W. M Detroit

Francis, Donald Detroit

Fraser, Harvey E Detroit

Fraser, H. F Detroit

Frazer, Mary Margaret Detroit

Freedman, John Detroit

Freedman, Milton Detroit

Freeman, D. K Detroit

Freeman, Mabel Detroit

. Freeman, Thelma Detroit

Freeman, Wilmer Detroit

Freese, John A Detroit

Fremont, Joseph C Detroit

Freund, Hugo A Detroit

*Friedlaender, Alex S Fort Custer

Frostic, Wm. D Detroit

Frothingham, George E Detroit

Fulgenzi, Andrew A Detroit

Fuller, Hugh M Grosse Pointe

Furey, Edward T Detroit

Gaba, Howard Detroit

Gabe, Sigmund Detroit

Gaberman, David B Detroit

Galantowicz, H. C Detroit

Galdonyi, Laslo L Detroit

Galerneau, D. B Van Dyke

Galvin, Paul P Detroit

Gamble, Parker B Detrojt

Gariepy, L. J Detroit

Gaston, Herbert B Detroit

Gehrke, August E Detroit

Geib, Ledru O Detroit

Geiter, Clyde W Detroit

Geitz, William A Detroit

Gellert, I. S Detroit

George, A. W Detroit

Gerondale, Elmond J Detroit

Gibson, James C Detroit

Giese, Fred W Detroit

Gigante, Nicola Detroit

Gignac, Arthur L Detroit

Gillespie, Stephen M Dearborn

Jour. ^I.S.M.S.

382

ROSTER FOR 1941

Gillman, R. W Detroit

Gingrich, Wayne A Detroit

Ginsberg, Harold I Detroit

Gitlin, Charles Detroit

Gittins, Perry C Detroit

Glasgow, Gordon K Detroit

Glassman, Samuel Detroit

Glazer, Walter S Detroit

Glees, J. L Detroit

Glick, M. J Detroit

♦Glickman, L. Grant

Minneapolis, Minn.

Glowacki, B. F Detroit

Gmeiner, Clarence C Detroit

Goerke, Elmer A Detroit

Goetz, Angus G Detroit

Goldberg, Arthur Detroit

Goldberg, Nathan H Detroit

♦Goldin, M. I Fort Custer

Goldman, Perry Detroit

Goldsmith, Joseph D Detroit

Goldstone, R. R Detroit

Gollman, Maurice D Detroit

Gonne, William S' Detroit

Goodrich, B. E Detroit

Gordon, John W Detroit

Gordon, William H Detroit

*Gorelick, Harry S. . . Camp Grant, 111.

Gorning, Raymond P Detroit

Gottschalk, Fred W .Detroit

Gould, S. Emanuel Eloise

Goux, R. S Detroit

Grace, Joseph M Eloise

Graff, J. M Detroit

Gratton, Henri L Detroit

Grain, Gerald O Detroit

Grajewski, Leo E Detroit

Granger, Francis L ■. . . .Detroit

Grant, Heman E Detroit

♦Gray, Arthur S Kalamazoo

Green, Lewis Detroit

Green, Louis M Detroit

*Green, Sydney H San Francisco

Greenberg, Julius J Detroit

♦Greenberg, Morris Z Fort Custer

Greene, John B Detroit

Greenidge, Robert Detroit

Greenlee, William Tate Detroit

Greiner, Bert A Detroit

Grekin, Joseph Detroit

Grekin, Samuel L Detroit

Grimaldi, G. J Detroit

Grob, Otto Detroit

Gronow, A. A Detroit

Gruber, T. K Eloise

Guerrero, Jose Detroit

Guimaraes, A. S Dearborn

Gurdjian, E. S Detroit

♦Gutow, Benj. R. .Fort McClellan, Ala.

Hale, Arthur S Detroit

Hall, Arche C. ..t Detroit

Hall, E. Walter Detroit

Hall, James A. J Detroit

Hall, Ralph E Detroit

Hall, Robert J Detroit

Haluska, Joseph A Detroit

H’Amada, Norman K Detroit

Hamburger, A. C Detroit

Hamil, Brenton M Detroit

Hamilton, Norman C Detroit

Hamilton, Stewart Detroit

Hamilton, William Detroit

Hamilton, William F Detroit

Hammer, Charles A Detroit

Hammer, Edwin J Detroit

Hammond, A. E Detroit

Hammond, James L Inkster

Hand, Fordus V Detroit

Hanna, E. Howard Detroit

Hanna, Samuel C Detroit

Hansen, Frederick E Detrojt

Hanson, Joseph Detroit

Hardstaff, R. John Detroit

Hardy, George C Detroit

Harkins, Henry N Detroit

Harley, Louis M Detroit

Harm, W. B Detroit

*Harper, Jesse T Fort Custer

Harrell, Voss Detroit

Harris, Harold H Detroit

Harrison, Henry Detroit

Harrison, Hugh Detroit

Harrison, Wesley Detroit

Hart, J. Clarence Detroit

Hartgraves. Hal'ie Detroit

Hartman, W. B Detroit

Hartzell, John B Detroit

Hasley, Clyde K Detroit

Hasley, Daniel E Detroit

Hasner, R. B Detroit

Hastings, Orville J Detroit

Hause, Glen E Detroit

Hauser, I. Jerome Detroit

May, 1941

Hauser, John E Detroit

Havers, Howard Detroit

Hawken, William C Detroit

Hawkins, James W Detroit

Hayes, Joseph D Detroit

Heath, Leo'nard P Detroit

Heath, Parker Detroit

Heavner, L. E Detroit

Hedges, Frank W Detroit

Hedrick, Donald W Detroit

Heenan, T. H. Detroit

Heideman, Louis Detroit

Heldt, Thomas J Detroit

Hendelman, Manuel H Detroit

*Henderson, A. B.'.Fort Bragg, N. C.

Henderson, Harold Detroit

Henderson, William E Detroit

Henderson, Wm. W Detroit

Henig, Fred Detroit

Herkimer, Dan R Lincoln Park

Herrold, Rose E Detroit

Herschelmann, Roy F Detroit

Hershey, Lynn N Detroit

Hewitt, Leland V Detroit

Heyner, Stanley A Detroit

Higbee, Arthur L Detroit

Hildebrant, Hugh R Detroit

Hileman, Lee Ecorse

Hillenbrand, A. E Detroit

Hillier, L. G Detroit

Hipp, William Detroit

Hirschman, L. J Detroit

Hochman, Morton M, Detroit

Hodge, James B Detroit

Hodges, Roy W Detroit

Hodoski, Frank J Detroit

Hoffman, E. S Detroit

Hoffman, Henry A Detroit

Hoffmann, Martin H Eloise

Hollander, A. J Detroit

Holman, Herbert H Detroit

Holmes, Alfred W Detroit

♦Holt, Henry T Fort Custer

Honhart, Fred L Detroit

Honor, William H Wyandotte

Hoobler, B. Raymond Detroit

Hookey, J. A Detroit

Hooper, Norman L Detroit

Hoopes, Benjamin F Detroit

Hoops, George B Detroit

Hopkins, J. E Detroit

Horan, Thomas Detroit

Horny, Hugo Detroit

Horton, Reece H Detroit

Horvath, Louis O Detroit

Horwitz, John B Detroit

Host, Lawrence N Detroit

Howard, Austin Z Detroit

Howard, Philip J Detroit

Howell, Bert F Detroit

Howell, Robert Eloise

Howes, Willard Boyden Detroit

Howlett. Howard T Detroit

Hromadko, Louis Detroit

Hubbard, John P Detroit

Hudson, A. Willis Detroit

Hudson, J. Stewart. .. .Grosse Pointe

Hudson, William A Detroit

Huegli. Wilfred A Detroit

HUjff, Reginald G Wayne

Hughes, Albertie A Detroit

Hughes, Ray W Detroit

Hull, L. W Detroit

Hunt, T. H. Detroit

Hunter, Basil H Detroit

Hunter, Elmer N Detroit

Husband, Charles W Detroit

Hyatt, Jarvis M Detroit

Hyde, F. W Detroit

lacobell, Peter H Detroit

Ignatius, A. A Detroit

Insley, Stanley W Detroit

Irwin, W. A Detroit

Isaacs, Joseph C Detroit

Israel, Barney B Detroit

Israel, J. G Detroit

Ivkovich, Peter Detroit

Jacoby, Myron D Detroit

Jaeger, Grove A Detroit

Jaeger, Julius P Detroit

Jaekel, C. N Detroit

Jaffar, Donald J Detroit

Jaffe, Jacob Detroit

Jaffe, J. L Detroit

Jaffe, Louis Detroit

Jahsman, William E Detroit

James, L. Mae Detroit

Jamieson, Robert C Detroit

Jarre, Hans A Detroit

Jarzembowski, F. B Detroit

Jarzynka, Frank J Detroit

Jasion, Lawrence J Detroit

Jend, William J Detroit

Jenkins, E. A Detroit

Jennings, Alpheus F Detroit

Jentgen, Charles J Detroit

Jentgen, L. G Detroit

Jennings, Robt. M Detroit

Jewell, F. C Detroit

Jodar, E. O Detroit

John, Hubert R Detroit

Johnson, Homer L Detroit

Johnson, Orlen J Detroit

Johnson, Ralph A Detroit

Johnson, R. M Detroit

Johnson, W. H. M. Detroit

Johnston, Everett V Detroit

Johnston, J. A Detroit

Johnston, John L Detroit

Johnston, William E Detroit

Johnstone, B. I Detroit

Joinville, E. V Detroit

Jones, Adrian R Detroit

Jones, Arthur J Detroit

Jones, H. C Detroit

Jones, L. Faunt Detroit

Jones, Roy D Detroit

Jonikaitis, Joseph J Detroit

Joyce, Stanley J Detroit

Judd, C. Hollister Detroit

♦Juliar, Benjamin Fort Custer

Kahn, William W Detroit

Kallet, Herbert I Detroit

Kallman, David Detroit

Kallman, Leo Detroit

Kallman, R. Robert Detroit

Kaminski, Ladislaus R Detroit

Kaminski, Zeno L Detroit

Kamperman, George A Detroit

Kapetansky, A. J Detroit

Kapetansky, Nathan J Detroit

Karr, Herbert S Detroit

Kasper, Joseph A Detroit

Kass, J. B Detroit

Katzman, I. S Detroit

Kaump, Donald H Detroit

Kay, Harry H Detroit

Kazdan, Morris A Dearborn

Keane, William E Detroit

Keemer, Edgar B Detroit

Keemer, T. Beatrice Detroit

Keene, Clifford H Wyandotte

Kehoe, Henry J East Detroit

Kelly, Edward W Detroit

Kelly, Frank A Detroit

Kemler, Walter J Ecorse

Kennary, James M Detroit

Kennedy, Charles S Detroit

Kennedy, Lester F Detroit

Kennedy, Robert B Detroit

Kenning, John C Detroit

Kenyon, Fanny H Detroit

Kern, W. H Garden City

Kernick, M. 0....1 Detroit

Kernkamp, Ralph Eloise

Kersten, Armand G Detroit

Kersten, Werner Detroit

Keshishian, Sarkis K Detroit

Kibzey, Ambrose T Detroit

Kidner, Frederick C Detroit

Kimbell, David C Detroit

Kimberlin, Kenneth K Detroit

King, Edward D Detroit

King, Melbourne J Detroit

Kingswood, Roy C Detroit

Kirchner, Augustus Detroit

Kirker, J. G Detroit

Kirschbaum, Harry M Detroit

Klebba, Paul Detroit

Klein, Louis Nutley, New Jersey

Klein, William Detroit

Kliger, David Detroit

Kline, Starr L Detrojt

Kloeppel, C. S Detroit

Klosowski, Joseph Detroit

Klote, M. D Detroit

Knaggs, Charles W Grosse Pointe

Knaggs, Earl J Wyandotte

Knapp, Byron S River Rouge

Knapp, Floyd Detroit

Knobloch, Edmund J Detroit

Knox, Ross M Ecorse

Koch, John C Detroit

Koebel, R. H Detroit

Koerber, Edw. J Detroit

Koessler, George L Detro't

Kohn. A. Max Detroit

Kohn, M. E Detroit

Kokowicz, Raymond J Detroit

Kolasa, W. B Detroit

K^pel, Joseph O Detroit

Korby, George J Detroit

Koss, Frank R Dearborn

Kossayda, Adam W Detroit

^Kovach, Emery.. Fort Jackson. S. C.
Kowalski, Valentine L Detroit

3S3

Kozlinski, Anthony E Detroit

Kraus, John J Detroit

Kreinbring, Geo. E Detroit

Kretzschmar, Clarence A Detroit

Krieg, Earl G Detroit

Krieger, Harley L Detroit

Kritchman, M. J Detroit

Kroha, Lawrence Detroit

Krohn, Albert H Detroit

Kubanek, Joseph L Eloise

Kucmierz, Francis S Detroit

Kulaski, Chester H Detroit

Kullman, Harold J Detroit

Kurcz, J. A Detroit

Kurtz, I. J Detroit

Kwasiborski, S. A Wyandotte

Laberge, James M Wyandotte

La Bine, Alfred C Detroit

LaCore, Ivan Detroit

La Ferte, Alfred D Detroit

Lakoff, Charles Detroit

Lam, Conrad R Detroit

♦Lammy, James V.

Camp Beauregard, La.

La Marche, N. O Detroit

Landers, M. B Detroit

Landers, Maurice B., Jr Detroit

Lang, Leonard W Detroit

Lange, Anthony H Detroit

Lange, William A Detroit

Laning, George M Detroit

Lapham, Fred E Detroit

Larson, John A Detroit

Larsson, Bror H Detroit

Lasley, James Wm Detroit

Lassaline, S. J Detroit

Latham, Ruth M Detroit

Lathrop, Philip L Detroit

Laub, Stanley V Detroit

Lauppe, Edw. H Detroit

Lauppe, F. A ' Detroit

Law, John H Detroit

Leach, David Detroit

Leacock, Robert C Detroit

Leader, L. R Detroit

Leaver, L. Ross Detroit

Leckie, George_ C Detroit

Ledwidge, Patrick L Detroit

Lee, Harry E Detroit

LeGallee, Geo. M Detroit

Leibinger, Henry R Detroit

Leiser, Rudolf Eloise

Leithauser, D. J Detroit

Leland, Sol Detroit

Lemley, Clark Detroit

Lemmon, Charles E .Detroit

Lemmon, Clarence W River Rouge

Lentine, James J Detroit

Lenz, Willard R Detroit

Lepard, C. W Detroit

Lepley, Fred O Detroit

Lerman, S. E Detroit

Lescohier, Alex W Grosse Pointe

L’Esperance, Simon P Detroit

Leszynski, J. S Detroit

Leucutia, Traian Detroit

Levant, Arthur B Detroit

Levin, David M Detroit

Levin, Samuel J Detroit

Levine, Sidney S Detroit

Levitt, Nathan Detroit

Levy, David J Detroit

Levy, Marvin B Detroit

Lewis, Charles T Detroit

Lewis, L. A Detroit

Lewis, J. Hugh Wyandotte

Lewis, Wilfred John ....Detroit

Libbrecht, Robert V Lincoln Park

Lieberman, B. L Detrojt

Liddicoat, A. G Detroit

Lightbody, James J Detroit

Lignell, Rudolph Detroit

Lilly, Charles J Detroit

Lilly, Vernon Detroit

Linton, James R Eloise

Lipkin, Ezra Detroit

Lipschutz, Louis S Eloise

Livingston, George D Detroit

Livingston, George M Detroit

Lockwood, Bruce C Detroit

Lofstrom, James E Detroit

Long, Earle C Detroit

Long, John J Detroit

Loranger, C. B Detroit

*Loranger, Guy L Rantoul, 111.

Lorber, Joseph Detroit

*Lord, Herman M Denver, Colo.

Lorentzen, Edwin H Detroit

Lovas, W. S Detroit

Love, W. Thomas Detroit

Lovering, William J Detroit

Lowrie, G. B Detroit

Lowrie, William L., Jr Detroit

ROSTER FOR 1941

Lowry, George L Detroit

Luce, Henry A Detroit

Lutz, Earl F Detroit

Lynn, David H Detroit

Lynn, Harvey D Detroit

Lyons, Richard H Eloise

Mabee, Frank P Detroit

Mabley, J. Donald Detroit

MacArthur, Robt Detroit

MacCraken, Frances L Detroit

MacGregor, W. W Detroit

Mack, Harold C Detroit

MacKenzie, Earle D Detroti

MacKenzie, Frank M Detroit

MacKenzie, John W Grosse Pointe

Mackersie, W. G Detroit

MacMillan, Francis B Detroit

MacMullen, Frank B Detroit

MacQueen, Malcolm D Detroit

Maczewski, John E Detroit

Madsen, Martha Detroit

Maguire, Clarence E Detroit

Mahlatjie, Nathaniel M Detroit

Mahoney, Hugh M Detroit

Maibauer, F. P Wyandotte

Maior, Roman H Detroit

Mair, Harold U Detroit

Maire, E. D Grosse Pointe

Malik, Edward A Detroit

Malik, Nur M Detroit

Malachowski, B. T Detroit

Malone, Herbert Detroit

Maloney, John A Detroit

Mancuso, Vincent S Detroit

Manting, Jacob Detroit

Maples, Douglas E Detroit

Marcotte, Oliver Detroit

Marcus, Daniel B Detroit

Marinus, Carleton J Detroit

Markel, Joseph M Detroit

Markoe, Rupert C. L Detroit

Marks, Ben Detroit

Markuson, Kenneth East Lansing

Marsden, Thomas B Detroit

Marsh, Alton R Detroit

Marshall, James R Detroit

Martin, Edward G Detroit

Martin, Elbert A Detroit

Martin, L. R Detroit

Martin, R. M Detroit

Martinez, P. O Detroit

Martmer, Edgar Grosse Pointe

Marwil, T. B Detroit

Mason, Percy W Detroit

Mateer, John G Detroit

Mathes, Charles J Detroit

Matthews, Wallace R Dearborn

Maun, Mark E Detroit

May, Earl W Detroit

May, Frederick T., Jr Detroit

Mayer, E. V Detroit

Mayer, Willard D Detroit

Mayer, William L Detroit

Mayne, C. H Detroit

Mayner, Frank A Wyandotte

McAfee, F. W Detroit

McAlonan, Wm. T Detroit

McAlpine, Archibald D Detroit

McAlpine, Gordon S Detroit

McClellan, G. L Detroit

McClellan, Robert J Detroit

McClendon, James J Detroit

McClintock, J. J Detroit

McClure, Roy D Detroit

McQure, William R Detroit

*McColl, Charles W. .. Alexandria, La.

McColl, Clarke M Detroit

McColl, Kenneth M Detroit

McCollum, E. B Detroit

McCord, Carey P Detroit

McCormick, Colin C ..Dearborn

McCormick, Crawford W Detroit

McCullough, Lester E Detroit

McDonald, Allan W Detroit

McDonald, Angus L Detroit

McDonald, George O Detroit

McDonald, Peter W Wyandotte

McDougall, B. W Detroit

McFadyen, Hugh A Detroit

McGarvah, A. W Detroit

McGarvah, Joseph A Detroit

McGillicuddy, Walter E Detroit

McGlaughlin, Nicholas . . . .Wyandotte

McGough, Joseph M Detroit

McGraw, Arthur B

Grosse Pointe Farms

McGuire, M. Ruth Detroit

McIntosh, W. V Detroit

McKay, Edwin B Detroit

McKean, G. Thomas Detroit

McKean, Richard M Detroit

McKenna, Charles J Detroit

McKinnon, John D Detroit

McLane, Harriett E Detroit-

McLaughlin, Nelson Detroit J

McLean, Don W Detroit*

McLean, Harold G Detroit

McPhail, Malcolm Detroit

McPherson, R. J Detroit

McQuiggan, Mark R Detroit ■

McQuiggan, Paul Detroit!

McRae, Donald H Detroit

Meader, F. M Detroit

Meek, Stuart F Grosse Pointe

Meinecke, Helmuth A. Detroit j

Mellen, Hyman S Detroit I

Melnik, Maxim P Detroit 7

Menagh, Frank R Detroit j

Mendelssohn, R. J Detroit 4

Merkel, Charles C 1

Grosse Pointe Village »

Merrill, Lionel N Detroit d

Merrill, William O Detroit ’

Merritt, Earl G Detroit

Metzger, Harry C Detroit ■■

Meyers, M. P Detroit (

Meyers. Solomon G Detroit -

Miley, H. H Detroit ^

Miller, Daniel H Detroit ^

Miller, Hazen L..., Detroit

Miller, Karl Detroit ’

Miller, Maurice P Trenton

Miller, Myron H Detroit t

Miller, T. H Detroit ‘

Mills, Clinton C Detroit *

Mills, Georgia V Detroit j

Miner, Stanley G Detroit

Minor, Edward G Detroit

Mintz, Edward I Detroit

Miral, Solomon P Detroit ■

Mishelevich, Sophie Detroit

Mitchell, C. Leslie Detroit

Mitchell, Gertrude F Detroit

Mitchell, W. Bede Detroit

Moehlig, Robert C Detroit

Moisides, V. P Detroit

Moll, Clarence D Detroit

Molner, Joseph G Detroit

Mond, Edward Detroit

Monfort, Willard Detroit '

Montante, Jos. R Detroit

Montgomery, John C Detroit

Morand, Louis J Detroit

Moriarity, George Detroit

Morin, John B Detroit

Moritz, H. C Detroit

Morley, James A Detroit

Morrill, Donald M Detroit

Morris, Harold L Detroit -

Morrison, Marjorie G. E Detroit

Morse, Plinn F Detroit

■“■Morton, David G.

Fort Sam Houston, Texas

Morton, J. B Detroit

Mosen, Max M Detroit

Moss, E. B Detroit

Muellenhagen, Walter J Detroit

Munro, Fred William Detroit

Munson, F. T Detroit

Muntyan, Andrew Detroit

Murphy, D. J Detroit

Murphy, Frank J Detroit

Murphy, John M Detroit

Murphy, Scipio G Detroit

Murphy, W. M Detroit

Murray, George M Detroit

Murray, William A Detroit

Muske, Paul H Detroit

Musser, Fred C Detroit

Myers, Gordon B Detroit

Nagel, Oscar Detroit

Nagle, John W Wyandotte

Naud, Henry J Detroit

Nawotka, Edward E Detroit

Naylor, A. E Detroit

Naylor, Arthur H Detroit

Neary, John H Detroit

Neeb, Walter G Detroit

Nelson, Harry M Detroit

Nelson, Victor E Detroit

Neumann, Arthur J Detroit

Newbarr, Arthur A Detroit

Newman, Max Karl Detroit

Nichamin, Samuel J Detroit

Nickerson, Dean Detroit

Nigro, Norman D Detroit

Nill, John B Detroit

Nill, William F Detroit

Nolting, Wilfred S Detroit

Norconk, A. A Detroit

Norris, Edgar H Detrojt

Northcross, Daisy L Detroit

Northrop, Arthur K Detroit

Norton, Chas. S Detroit

Noth, Paul H Grosse Pointe Farms

Novy, R. L Detroit

Jour. M.S.M.S.

384

ROSTER FOR 1941

Nowicki, Joseph A Detroit

O’Brien, E. J Detroit

O’Donnell, Dayton H Detroit

Ohmart, Galen B Detroit

O’Hora, James T Detroit

Olechowski, L Detroit

Olenikofl, Alex Detroit

Olney, H. E Detroit

Oman, Cyrus F Detroit

Oppenheim, J. M Detroit

Oppenheim, Milton M Detroit

Organ, Fred W Detroit

Ormond, John K Detroit

O’Rourke, Randall M Detroit

Osius, Eugene A Detroit

Osowski, Felix A Detroit

Ottaway, John P Detroit

Ottrock, Anton Detroit

Owen, Clarence I Detroit

Owen, Robert G Detroit

I

Palmer, Hayden Detroit

Palmer, R. Johnston Detroit

Palmerlee, George H Detroit

Pangburn, L. E Detroit

Panzner, Edward J Detroit

Parker, Walter R Detroit

Parr, R. W Detroit

Parsons, John P. ...Grosse Pointe Park

Pasternacki, Norbert T Detroit

Patterson, Walter G Detroit

Pawlowski, Jerome Detroit

Paysner, Harry A.... Detroit

Peabody, Charles William Detroit

Peacock, Lee W Detroit

Pearse, Harry A Detroit

Peggs, George F Detroit

Peirce, Howard W Detroit

Penberthy, G. C Detroit

Pequegnot, Charles F Detroit

Perdue, Grace M Detroit

Perkin, Frank S Detroit

Perkins, Ralph A Grosse Pointe

Perlis, H. L Detroit

♦Perry, Alvin LaForge..El Paso, Texas

Peterman, Earl A Detroit

Pfeiffer, Rudolph L Detroit

Phillips, Fred W Detroit

Pickard, Orlando W Detroit

Pierce, Frank L Detroit

Pierson, Merle Detroit

Pinckard, Karl G Dearborn

Pink, Rose M Detroit

Pinney, Lyman J Detroit

Pinoi, Ralph H Detroit

Piper, Clark C Detroit

Piper, Ralph R Detroit

Plaggemeyer, H. W Detroit

Plain, George Detroit

Pliskow, Harold Detroit

Podezwa, J. W Hamtramck

Pollock, John J Detroit

Poole, Marsh W Detroit

Poos, Edgar E Detroit

Porretta, Anthony C Detroit

Porretta, F. S Detroit

Porter, Howard J Romulus

Posner, Irving Detroit

Potts, E, A Detroit

Pratt, Jean P Detro’t

*Pratt, Lawrence. . .Fort Sheridan, 111.

Prendergast, John J Detroit

Priborsky, Benjamin H Detroit

Price, A. H Detroit

Price, Alvin Edwin Detroit

Proud, Robert H Flat Rock

Ptolemy, H. H Detroit

Pugliesi, Benedetto Detroit

Purcell, Frank H Detroit

Putra, A. M .Detroit

Pyle, Wynand Mountclair, N. J.

Quigley, William Detroit

Rabinovitch, Bella Detroit

Rahm, Lambert P Detroit

Raiford. Frank P Detroit

Rand, Morris Detroit

Raskin, Morris Detroit

Rastello, Peter B Detroit

Ratigan, C. S Dearborn

Raynor, Harold F Detroit

Reberdy, George J Detroit

Reed, £. Hobart Grosse Pointe

Reed, H. Walter Detroit

Rees, Howard C Detroit

•Reid, Wesley G. ...Fort Benning, Ga.

Reiff, Morris V Detroit

Reinholt, Charles A Detroit

Reinsh, Ernest R Detroit

Rekshaw, W. R Dearborn

Renaud, G. L Detroit

Rennell. Leo P Detroit

Renz, Russell H Detroit

Repp, William A Detroit

•Reske, Alven.Fort Sam Houston, Tex.

Reveno, William S Detroit

Rexford, Walton K Detroit

Reye, H. A Detroit

Reyner, C. E Detroit

Reynolds, Lawrence Detroit

Reynolds, R. P Detroit

Rezanka, Harold J Detroit

Rhoades, F. P Detroit

Rice, C, Malcolm, Jr Detroit

Rice, Harold B Detroit

Rice, Meshel Detroit

Richards, R. Milton Detroit

Richardson, Allan L Detroit

Elichardson, Robert P Wayne

Richey, Bert R Detroit

Rick, Paul Detroit

Ridge, Ralph W Wyandotte

Ridley, Edward R Detroit

Rieckhoff, George G Detroit

Rieger, John B Detroit

Rieger, Mary H Detroit

Riseborough, E. C Detroit

Rizzo, Frank Detroit

Robb, Edward L Detroit

Robb, Herbert F ..Belleville

Robb, J. M Grosse Pointe Village

Roberts, Arthur J Ecorse

Robertson, A. E Detroit

Robertson, Stanley B Detroit

Robertson, Tom H Detroit

Robillard, Henry Detroit

Robinson, George W Detroit

*Robinson, Harold A. .Scott Field, 111.

Robinson, R. G Detroit

•Rogers, A. Z Grosse Pte. Woods

Rogers, James D Wyandotte

Rogin, James R Detroit

Rogoff, A. S Detroit

Rohde, Paul C. Detroit

Roman, Stanley J Detroit

*Root, Charles T...Fort Sam Houston

Rosbolt, Oscar P Detroit

Rose, Bernard Detroit

Rosenman, J. D Detroit

Rosenthal, Louis H Detroit

Rosenthall, M. J Detroit

Rosenwach, Felix F Detroit

Rosenzweig, Saul Detroit

Ross, D. G Grosse Pointe

Ross, Ben C Detroit

Ross, Samuel H Detroit

Rotarius, E. M Detroit

Roth, Theodore I Detroit

Rothbart, H. B Detroit

Rothman, Emil D Detroit

Rottenberg, Leon Detroit

Rowda, Michael S Detroit

Rowell. Wilfred J Detroit

Rubright, LeRoy W Detroit

Rucker, Julian J Detroit

Rueger, Milton J Detroit

Rueger, Ralph C Detroit

Runge, Edward F Detroit

Rupp, Jacob R Detroit

Rupprecht, Emil F Detroit

Ruskin, Samuel H Eloise

Russell, John C Detroit

Ryan, Charles F Detroit

Ryan, W. D Detroit

Rydzewski, Joseph B Detroit

Ryerson, Frank L Detroit

Sachs, Herman K Detroit

Sachs, Ralph Robert Detroit

Sack, A. G. Detroit

Sadowski, Roman Detroit

Sage, Edward O Dearborn

Sager, E. L Detroit

St. Louis, R. J Detroit

Salchow, Paul T Detroit

Salisbury, Howard W Dearborn

Salowich, John N Detroit

Saltzstein, Harry C Detroit

Sander, I. W Detroit

Sanders, Alex W Detroit

Sanderson, Alvord R

Grosse Pointe Park

Sanderson, James H Detroit

Sanderson, Suzanne Detroit

Sandler, Nathaniel Detroit

Sandweiss, David J Detroit

Sanford, Hawley S Detroit

Sands, G. E Detroit

Sargent, William R Detroit

Savignac, Eugene M Detroit

Sawyer, Harold F Detroit

Scarney, Herman D Detroit

Schaefer, Robert L Detroit

Schaeffer, Martin Detroit

Schembeck, I. S Detroit

Schenden, A. J Melvindale

Schinagel, Geza Detroit

Schlacht, George F Romulus

Schlafer, Nathan H i Detroit

Schmidt, Harry B Detroit

Schmidt, Milton R Trenton

Schmier, Burton L Detroit

Schmitt, Norman L Detroit

Schneck, Robert J Detroit

Schneider, Curt P Detroit

Schoenfield, Gilbert D Detroit

Schooten, Sarah S Detroit

Schreiber, Frederick Detroit

Schroeder, Carlisle F Detroit

Schultz, Ernest C Detroit

Schultz, Robert F Detroit

Schwartz, H. Allen Detroit

Schwartz, Louis A Detroit

Schwartz, Oscar D Detroit

Schwartzberg, Jos. A Detroit

Schweigert, C. F Detroit

Sciarnno, Stanley V Detroit

Scott, R. J Detroit

Scott, Wm. J Grosse Pointe Farms

Scruton, Foster D Detroit

Seabury, Frank P Detroit

Secord, Eugene W Detroit

Seeley, Ward F Detroit

Segar, Lawrence F Detroit

Seibert, iUvin H Detroit

Selb^ C. D. Detroit

Seliady, Joseph E Northville

Sellers, Charles W. Detroit

Selling, Lowell Detroit

Selman, J. H... Detroit

Sewell, George S Detroit

Seymour, William J Detroit

Shafarman, Eugene Detroit

Shaffer, Joseph H Det^Cff

Shaffer, Loren W. ..Grosse Pointe Park

Shatter, Royce R Detroit

Sharrer, Charles H Detroit

Shaw, Robert G Detroit

Shawan, H. K Detroit

Shebesta, Emil Detroit"

Sheldon, John A '.Detroit

Shelton, C. F Detroit

Sheridan, Charles R Detroit

Sherman, B. B Detroit

Sherman, William L Detroit

Sherrin, Edgar R Detroit

Sherwood, DeWitt L Detroit

Shields, William L Detroit

Shifrin, Peter G Detroit

Shlain, Benjamin Detroit

Shore, O. J Detroit

Shotwell, Carlos W Detroit

Shulak, Irving B Detroit

Shurly, Burt R Detroit

Siddall, Roger S Detroit

Siefert, John L Detroit

Siefert, William A Detroit

Siegel, Henry Dearborn

Sill, Henry W Detroit

Silvarman, I. Z Detroit

Silverman, M. M Detroit

Simon, Emil R Dearborn

Simpson, C. E Detroit

Simpson, H. Lee Detroit

Sippola, George W Detroit

Sisson, John M Detroit

Siwka, Isidore J Detroit

Skinner, W. Clare Detroit

Skolnick, Max H Detroit

Skrzyeki, Stephen S Detroit

Skully, E. J Detroit

Skully, G. A Detroit

Sladen, Frank J Detroit

Slate, Raymond N Detroit

Slaugenhaupt, J. G Detroit

Slaughter, Wayne B... Detroit

Slazinski, Leo W Detroit

Slevin, John G Detroit

Slipson, Edith G Detroit

Sliwin, Edward P Detroit

Small, Henry Detroit

Smeefc, Arthur R Detroit

Smeltzer, Merrill Detroit

Smith, Clarence V Detroit

Smith, Claude A River Rouge

Smith, Eugene, Jr Detroit

Smith, F. Janney Detroit

Smith, Fred R Detroit

Smith, Gerritt Calvin Detroit

Smith, Henry L Detroit

Smith, J. Allen.. Detroit

Smith, James A Detroit

Smith, L. Lloyd Detroit

Snedeker, Bernard C. . . . Highland Park

Snow, L. W Northville

Socall, Charles J Detroit

Sokolov, Raymond A Detroit

Somers, Donald C Detroit

Sonda, Lewis P Detroit

•Sorock, Milton L Fort Custer

Souda, Andrew Wyandotte

May, 1941

385

ROSTER FOR 19-11

Spademan, Loren C Detroit

Spalding, Edward D Detroit

Sparling, Harold I Northville

Sparling, Irene L Northville

Speck, Carlos C Detroit

*Spector, Maurice J. ..Fort Sill, Okla.

Spencer, Frank Detroit

Spero, Gerald D Detroit

Sperry, Frederick L Detroit

Spiro, Adolph Detroit

Springborn, B. R Detroit

Sprunk, Carl Detroit

Sprunk, John P Detroit

Squires, W. H Eloise

Stafford, Frank W. J Detroit

Stageman, John Condon Detroit

Stalker, Hugh Grosse Pointe

Stamell, Meyer Detroit

Stamos/ Harry F Detroit

Stanton, James M Detroit

Stapleton, William J., Jr Detroit

Starrs, Thomas C Detroit

Stefani, E. L Detroit

Stefani, Raymond T Detroit

Stein, Emory Detroit

Stein, Saul C Detroit

Steinbach, Henry B Detroit

Steinberger, Eugene Detrojt

Steiner, Max Detroit

Steinhardt, Milton J Detroit

Stellhorn, Chester E Detroit

Stellhorn, Mary Christine Detroit

Sterling, Lawrence Detroit

Sterling, Robert R Detroit

Stern, Edward A Detroit

Stern, Harry L Detroit

Stern, Louis D Detroit

Stevens, Rollin H Detroit

Stewart, Harry L Detroit

Stewart, Thomas O Detroit

Stirling, Alex M Detroit

Stockwell. B. W Detroit

Stokfisz, T Detroit

Stout, Lindley H Detroit

Stover, R. F Detroit

Straith, Claire L Detroit

Strieker, Henry D Detroit

Strickland, C. C Detroit

Strickroot, Fred L Detroit

Strohschein, Don F Detroit

Struthers, J. N. P Detroit

Stubbs, C. T Detroit

Stubbs, Harold W Detroit

Sugarman, Marcus H Detroit

Sullivan, Hugh A Detroit

Summers, William S Detroit

Surbis, John P Detroit

Sutherland, J. M Detroit

Swanson, Cleary N Detroit

Swartz, J. N Detroit

Swift. Karl L Detroit

Switzer, B. C Detroit

Syphax, Charles S., Jr Detroit

Szappanyos, Bela T Detroit

Szedja, J. C Detroit

Szmigiel, A. J Detroit

Tamblyn, E. J Detroit

Tann, H. E Detroit

Tapert, R. T Detroit

Tassie, Ralph N Detroit

Tatelis, Gabriel Detroit

Taylor, Nelson M Grosse Pointe

Taylor, Reu Spencer Detroit

Tear, Malcolm J Detroit

Teitelbaum, Myer Detroit

Tenaglia, Thomas A Ecorse

Texter, Elmer C Detroit

*Thomas, Alfred E. .Fort Bragg, N. C.

Thomas, Fred W Detroit

Thompson, H. O Detroit

Thompson, James B Detroit

'^hompson, W. A Detroit

Thomson, Alexander Detroit

Thosteson, George C Detroit

Albi, R. W Lake City

Brooks, G. W. .' Tustin

Gruber, John F Cadillac

*Hoagland, F. L Porto Rico

Holm, Augustus I.eroy

Holm, Benton Cadillac

Hoverter, J. W Evart

Tomsu, Charles L Detroit

Top, F. H Detroit

Torrey, H. N Detroit

Townsend, Frank M Detroit

Trask, Harry D Detroit

Tregenza, W. Kenneth Detroit

Trinity, Granville J Detroit

Troester, George A Detroit

Trombley, Bryan Detroit

Trombley, Joseph J., Jr Detroit

Troxell, Emmett C Detroit

Truszkowski, E. G Hamtramck

Tryon, Mary Detroit

Trythall, S. W Detroit

Tufford, Norman G Detroit

Tulloch, John Detroit

Tupjper, Roy D Detroit

Turbett, Claude W Detroit

Turcotte, Vincent J Detroit

Turkel, Henry Detroit

Ulbrich, Henry L. . Detroit

Ulrich, Willis H Detroit

Umphrey, Clarence E Detroit

Usher, William Kay Detroit

Vale, C. Fremont Detroit

VanBaalen, M. R Detroit

VanBeceLaere, Lawrence H Ecorse

Van de Velde, Honore Detroit

VanGundy, Clyde R Detroit

Van Heldorf, Harry Detroit

Van Rhee, George Detroit

Van Riper, Steven L Eloise

Vardon, Edward M Detroit

Vasu, V. O Detroit

Vergosen, Harry E Detroit

Vernier, Jean A Detroit

Vincent, J. LeRoi Wayne

Voegelin, Adolph E Detroit

Voelkner, George H Detroit

V^ogel, Hyman A Detroit

Vokes, Milton D Detroit

Von der Heide, E. C Detroit

Voorheis, Wilbur J Detroit

Vossler, A. E Detroit

Vreeland, C. Emerson Detroit

Waddington, Joseph E. G Detroit

Wadsworth, George H Detroit

Waggoner, C. Stanley Detroit

Wainger, M. J ' Detroit

Waldbott, George L Detroit

Walker, Enos G Detroit

Walker, J. Paul Detroit

Walker, Roger V Detroit

Wallace, S. Willard Detroit

Walls, Arch Detroit

Walser, Howard C Detroit

Walsh, Charles R Detroit

Walters, Albert G Detroit

Waltz, Frank D. B Detroit

Wander, William G Detroit

Ward, W. K Detroit

Warden, Horace F. W Detroit

Warner, Harold W Detroit

Warner, P. L Detroit

Warren, Wadsworth Detroit

Watson, Ernest Hamilton

Watson, Harwood G Dearborn

Watson, j. Edwin Detroit

Watson, Robert W Highland Park

Watts, Frederick B Detroit

Watts, John J Detroit

Wax, John H Detroit

Wayne, M. A Detroit

Weaver, Clarence E Detroit

Wehenkel, Albert M Detroit

Weiner, M. B Detroit

Weingarden, David H Detroit

Weinstein, Jacob Detroit

Weisberg, Harry Detroit

Weisberg, Jacob Detroit

Wexford-Kalkaska-Missaukee Counties

Laughbaum, T. R Lake City

McManus, Edwin Mesick

Masselink, H. J McBain

Merritt, C. E Manton

Mills, Robert E Boon

Moore, G. P Cadillac

Moore, Sair C Cadillac

Weiser, Frank A Detroit

Welch. John H Detroit

Weller, Charles N Detroit

Wellman, W. W Detroit

Wells, Martha Detroit

Weltman, Carl Detroit

Wendel, Jacob S Detroit

Wenzel, Jacob F Detroit

Wershow, Max Detroit

Westlund, Norman Dearborn

Weston, Earl E Detroit

Westover, Charles Detroit

Weyher, Russell F Detroit

Whalen, Neil J Detroit

Wharton, Thomas V Detroit

White, Milo R Detroit

White, Prosper D Detroit

Whitehead, L. S Detroit

*Whiteley, Robt. E. .. Philippine Islands

Whitney, Elmer L Detroit

Whitney, Rex E Detroit

Whittaker, Alfred H Detroit

Wiant, R. E. Detroit

Wickham, A. B Detroit

Wiener, I Detroit

Wight, Fred B Detroit

Wilcox, Leslie F. Detroit

Wilkinson, Arthur P Detroit

Williams, C. J Detroit

Williamson, Edwin M Detroit

Willis, Henry S Northville

Willis, Willard S Detroit

Wills, J. N Detroit

*Willson, Wesley W.

Fort Sheridan, 111.

Wilson, C. Stuart Detroit

Wilson, Gerald A Detroit

Wilson, James Leroy Detroit

Wilson, John D Detroit

Wilson, M. C Detroit

Wilson, Walter J Detroit

Wilson, Walter J., Jr Detroit

Winfield, James M Detroit

*Winsor, Carlton Webb.. Porto Rico

Wishropp, E. A Detroit

Wissman, H. C Detroit

Wittenberg, Arthur A Detroit

Wittenberg, Samson S Detroit

Wittenberg, Sydney S Detroit

Witter, Frank C Detroit

Witter, Joseph A Detroit

Witus, Morris Detroit

Witwer, Eldwin R. . Grosse Pointe Park

Wolfe, Ma.x O Detroit

Wollenberg, Robert A. C Detroit

Woodry, Norman L Detroit

Woods, H. B Detroit

Woods, W. Edward Detroit

Woodworth, William P Detroit

Wreggit, W. R Highland Park

Wruble, Joseph Detroit

Wygant. Thelma Detroit

Yesayian, H. G Detroit

Yonkman, Frederick F Detroit

Yott, William J Detroit

Young, Donald Andrew Detroit

Young, Donald C Detroit

Young, James P Detroit

Young, Lloyd B Detroit

Young, Viola M Detroit

Zbudowski, A. S Detroit

*Zbudowski, Myron R Fort Custer

Zemens, Joseph L.

Grosse Pointe Woods

Zielinski, Charles J Detroit

Zimmerman, Israel J Detroit

Zimmerman, R. L Detroit

Zinn, George H Detroit

Zinterhofer, John Detroit

Zinterhofer, Louis Detroit

Zlatkin, Louis Detroit

Zolliker, Carl R Detroit

Zukowski, Sigmind A Detroit

Murphy, Michael R Cadillac

Purdy, Calvin S Buckley

Seltzer, Sol N Marion

Showalter, Laurence E Cadillac

.Smith, Wallace J Cadillac

Tornberg, D. C Cadillac

Wood, George H Reed City

386

Jour. M.S.M.S.

What Value Membership?

☆

The value of membership in the Michigan State
Medical Society, as in any organization, depends upon
the interest and activity of the individual member.
In the vernacular, “one gets out of an organization
just what he puts into it.”

However, there are certain advantages which accrue
unconsciously and automatically to every member of
the Michigan State Medical Society, whether he stops
to “clip his coupons” or not. These have been classed
as : I. Educational and Professional, II. Economic,

and III. Sociologic. They are the valuable “intan-
gibles” which cannot be grasped like a silver dollar,
but are comparable to government bonds which of
themselves are mere bits of printed paper but repre-
sent and are backed by the wealth of the nation.

The greatest benefit of membership comes from the
very membership itself — the joining of hands and
working together, i.e.. Unity! A united' medical pro-
fession can readily achieve and hold its rightful posi-
tion of influence and leadership in the community and
the State. The maintenance of these qualities of in-
fluence and leadership is, therefore, the responsibility
of every one of the individual members of the Michi-
gan State Medical Society. Stand fast, together, as
one !

President, Michigan State Medical Society

May, 1941

387

EDITORIAL

-K

MUSKEGON HONORS
GEORGE L. LE FEVRE

■ George L. LeFevre, M.D., president of the
Michigan State Medical Society in 1932-33,
finished his fiftieth year of active practice March
19, 1941. The Muskegon County Medical Society
obtained the cooperation of the Muskegon
County Dental Society, the Chamber of Com-
merce and the Rotary Club in honoring “Dr.
George,” as he is familiarly known, in a com-
munity banquet.

Leaders of almost all groups of the city were
present and voiced their respect and admiration
for Doctor LeFevre.

The principal address, “The Army’s Depend-
ence upon the Medical Profession,” was given by
Dr. Burton R. Corbus, ex-president of the Michi-
gan State Medical Society and close friend of
Doctor LeFevre.

The Michigan State Medical Society was rep-
resented by President P. R. Urmston and Sec-
retary L. F. Foster. Doctor Urmston conveyed
to the honored guest the congratulations and
recognition of service from the profession of
Michigan.

“Dr. George’s” record is best expressed by the
following editorial from the Muskegon County
Medical Society Bulletin:

It is not given to many doctors of medicine to
complete fifty years of activity in their profession.
That experience alone makes a community celebration
noteworthy. Fifty years of practice means that many
generations of one family have been cared for by one
physician and that his name has become almost a
tradition in that family. There are a number of these
families, in Muskegon, to whom “Dr. George” has
been the symbol for relief from pain and surcease
from travail.

It is not given to many physicians to be elected
president of a great state medical society. That elec-
tion means that his colleagues recognize the unselfish
work he has done over a period of many years, and
also his unusual executive ability and leadership.

It is not given to many physicians to be the Chief-
of-Staff in a large hospital for thirty-eight years and
be the main activating influence of its growth.

It is not given to many physicians to be president
of a great bank, a large bank, to share the responsi-
bility of the financial structure of a city.

It is not given to many physicians to have an active
leading part in the political administration of a com-
munity and guide its development.

It is not given to many physicians to be a leader of
an active industrial foundation which has strengthened
the backbone of his home city.

It is not given to many physicians to be a prominent
member of a city’s service, fraternal, and social
organizations.

It is not given — but we could go on for another
page or two listing the accomplishments recorded and
the honors given; not just one, or tv'o, or three of
them, but all to George L. LeFevre.

The Muskegon County Medical Society has invited
the Muskegon County Dental Society, the Greater
Muskegon Chamber of Commerce, and the Rotary
Club to join in a community banquet honoring the
only physician in Michigan who has achieved, the
hard way, all these honors.

It redounds to the credit of the entire medical
profession and particularly the Muskegon County
Medical Society that our “Dr. George” is the honored
guest of such a meeting.

THE AMA NEEDS A NEW CHARTER .

■ The American Medical Association and its ;

local society in Washington, D. C., have been
convicted by a federal jury of violating the anti-
trust law. At the same time the jury acquitted j
all of the individual defendants, who included ,
the principal executive employes of the associa- ,
tion. ^

This verdict had a parallel some months ago i
in the federal court at South Bend, where the
General Motors corporation was convicted of '
violating the anti-trust laws in financing the sale
of its cars, but all of the officers of the corpora-
tion were acquitted. This, as it turned out, was
most fortunate for Mr. Roosevelt. It saved him
the embarrassment of plucking one of the defend-
ants, Mr. Knudsen, out of jail when he needed
him to head OPM.

The jurors seem to have been in no doubt
that a crime was committed, yet when they were ,
asked to say who committed it their answer *
was, “Nobody.” Perhaps the legal metaphysi- '
dans can straighten us out. Queries might well
be addressed to the prosecutor of the case, Mr.
Thurman Arnold, who has written that anti-

Tour. M.S.M.S.

EDITORIAL

trust prosecutions are a sham anyway, being de-
signed to propitiate the public conscience for
allowing acts that our moral sense tells us are
wrong but which our practical judgment says
are necessary.

The charge against the doctors at Washington
was that they engaged in a conspiracy in re-
straint of trade against the Group Health asso-
! elation, an organization that undertook to furnish
government employes with medical care in re-
turn for a flat monthly fee. The AMA asserts
that arrangements of this type tend to lower
the standards of medical care, and in conse-
quence its members, at the instigation of the
association’s leaders, refused to have any pro-
fessional relations with the physicians hired by
the Group Health organization.

The anti-trust conviction may impress upon the
members of the AMA that when they organized
they took out the wrong kind of a charter. They
should have applied to William Green or John
L. Lewis. So equipped, they would not have been
reduced to refusing to practice in the same hos-
pitals with a physician who signed up with Group
Health. Dr. Morris Fishbein could just have
gone around some evening and broken the
wrong guy’s fingers with a blackjack, an operation
that does a surgeon no more good than it does
a musician, and Mr. Justice Frankfurter would
have told Thurman Arnold not to get himself
all wrought up over a passing moment of animal
exuberance.

A good broad AFL or GIO charter would
solve a lot of the medical profession’s economic
problems. Its members would not have to worry
about overproduction of doctors. They could just
close their membership rolls and have some of
their members, sitting on the state and local ex-
amining boards, prosecute the newcomers for
practicing without a license.

Draft boards wouldn’t be asking physicians to
give their services free for examination of the
draftees. All the chest thumping in charity wards
would be done at the union scale and any non-
union medico who tried to cut in on the busi-
ness would have to pay $1,000 initiation fee.
Ladies expecting offspring would have to be
careful that the labor pains did not start after
4 p. m. on a Friday; otherwise Papa would have
to pay double time for a week-end delivery.

The medical union might be able to take on a
number of profitable activities that AMA mem-

bers now deny themselves, such as performing
abortions or, for a suitable fee, slipping a dose
from the black bottle to millionaires whose heirs
were growing impatient. While such activities
might arouse public protest, the union docs
could be sure that President Green would not
bother them. That would be interfering with
their autonomy. — Editorial, Chicago Daily Trib-
une, Monday, April 7, 1941. Reprinted by spe-
cial permission.

The Mary E. Pogue School

For Exceptional Children

DOCTORS: You may continue to super-
vise the treatment and care of children
you place in our school. Catalogue on
request.

WHEATON, ILLINOIS

85 Geneva Road Telephone Wheaton 66

Cook County

Graduate School of Medicine

(In Affiliation with Cook County Hospital)

Incorporated not for profit
ANNOUNCES CONTINUOUS COURSES

SURGERY — Two Weeks Intensive Course in_ Surgical
Technic with practice on living tissue, starting every
two weeks. General Courses, One, Two, Three and
Six Months; Clinical Courses; Special Courses. Rectal
Surgery every week.

MEDICINE — Two Weeks Intensive Course starting
June 2. Two Weeks Course in Gastro-Enterology
starting June 16. Four Weeks Course in Internal
Medicine starting August 4. One Month Course in
Electrocardiography and Heart Disease every month,
except August.

FRACTURES & TRAUMATIC SURGERY— Two
Weeks Intensive Course starting June 30. Informal
Course every week.

GYNECOLOGY — Two Weeks Intensive Course starting
June 16 and October 20. Clinical, Diagnostic and
Didactic Course every week.

OBSTETRICS — Two Weeks Personal Course starting
May 26. Two Weeks Intensive Course starting Octo-
ber 6. Informal Course every week.

OTOLARYNGOLOGY — Two Weeks Intensive Course
starting September 8. Informal and Personal Courses
every week.

OPHTHALMOLOGY — Two Weeks Intensive Course
starting September 22. Informal Course every week.

ROENTGENOLOGY — Courses in X-Ray Interpretation,
Fluoroscopy, Deep X-Ray Therapy every week.

Genercd, Intensive and Special Courses in
All Branches of Medicine, Surgery and
the Specialties.

TEACHING FACULTY — ATTENDING
STAFF OF COOK COUNTY HOSPITAL

Address:

Registrar, 427 South Honore St., Chicago, Illinois

May, 1941

’389

YOU AND YOUR BUSINESS

MEMBERSHIP INCREASE

January 1, 1934, 3160 members
January 1, 1935, 3393 members

January 1, 1936, 3650 members.

January 1, 1937, 3725 members.

January 1, 1938, 3963 members.

January 1, 1939, 4205 members.
January 1, 1940, 4383 members.
January 1, 1941, 4521 members.

The Michigan State Medical Society has
gained 1,361 members in seven years, an increase
of over 30 per cent.

A few eligible Doctors of Medicine are not
members of their county and state societies.
Members are urged to invite their reputable con-
freres to become associated with them in their
medical organization activities.

LEGISLATION FOR CRIPPLED
AND AFFLICTED CHILDREN

The Executive Committee of The Council,
Michigan State Medical Society, has gone on
record approving House Bill No. 317 and Senate
Bill No. 250 (identical bills) to simplify admin-
istration of laws dealing with afflicted and crip-
pled children. This proposal has also been ap-
proved by the American Legion, Forty and
Eight, Veterans of Foreign Wars, Michigan
Crippled Children Society, Michigan Hospital
Association, Michigan Welfare League and by
members of the Michigan Crippled Children
Commission.

This bill will eliminate unnecessary duplication
and investigation (and permanent confusion) by
placing authority and responsibility in one body
(the commission) — not in three agencies, as has
been Michigan’s unfortunate experience during
the past six years. Elimination of a multi-head-
ed administration will solve most of the problems
which have plagued the administration of laws
covering the care of crippled and afflicted chil-
dren.

Sincerely believing that HB-317 and SB-250
will best serve the unfortunate children, properly
remunerate the purveyors of the various services,
and protect the authorities charged with payment
for services, the Michigan State Medical Society
not only endorses this measure, but urges its

members actively to help towards the early pas-
sage of this fine proposal.

Doctors, as physicians and as taxpayers, are in-
vited by the Michigan State Medical Society of-
ficers to do all in their power to streamline these
laws which intimately touch their daily practice.
This can be done only by effective legislative con-
tact.

WORKMEN'S COMPENSATION LAW
ON CHOICE OF HEALER

“Is an employer responsible for bills incurred
by an injured workman who seeks aid from a
healer other than a doctor selected by the em-
ployer ?”

This question was recently asked by the medi-
cal director of a large Michigan corporation.

The answer is that an employer is not responsi-
ble for bills incurred by an injured workman who
seeks aid from a healer, other than the doctor se-
lected by the employer, without the knowledge of
the employer (except in an emergency where life
is in danger and where -the employer has been
notified within a reasonable period of time after
rendition of any first-aid services).

The medical director of a corporation is not
under any compulsion, by the state law, to refer
an injured workman to a healer, other than the
doctor selected by the corporation, for the care of
injuries, even at the workman’s insistence. All
supreme court cases in Michigan on this point
state that the employer generally has the right
to choose a doctor for his employee (Gardner v.
Michigan, 231 Mich. 331 is the leading Supreme
Court decision).

In the Workmen’s Compensation Act, Section
8420 reads : “During the first ninety days after
the injury the employer shall furnish or cause to
be furnished reasonable medical, surgical and
hospital services and medicines when they are
needed.” Therefore, it is the right and responsi-
bility of the employer only to select medical
services for injured employees; the desires of the
insurance carrier or the demands of the employee
to seek the services of healers other than the doc-
tor of medicin-e selected by the employer are of
no legal avail.

(Continued on Page 392)

390

Jour.

A Reminder from Borden about

FOUR KEY PRIIVCIPIES
IN INFANT FEEDINCi

I OUR KEY PRINCIPLES in infant feeding make Biolac the out-
standing prepared-formula liquid infant food:

1. Fat Adjustment: In Biolac, the fat content is reduced to a
moderate, readily assimilahle level— and is homogenized to
pro\dde smaller, more readily digestible fat droplets.

2. Protein Concentration: In Biolac, protein is similarly
homogenized for easier digestibility. It is maintained at a
somewhat higher level than in breast milk to provide ample
protein for the period of fastest growth.

3. Carbohydrate Adjustment: In Biolac, as in breast milk,
carbohydrate is provided solely by lactose— nature’s sole car-
bohydrate for the first few months of all mammalian life.

4. Vitamin Adjustment: In Biolac, Vitamins A, Bi, and D,
also iron, are supplied in accepted amounts, assuring the
baby of a constant and adequate supply.

Biolac needs only to be mixed with boiled water. It is sold
only in drugstores; and no directions are given to the laity.

Please enclose professional card or letterhead when
requesting literature or samples. The Borden Co.,
350 Madison Ave., New \ork City.

*

Mil—

May, 1941

Say yon sazo it in the Journal of the Michigafi State Medical Society

391

YOU AND YOUR BUSINESS

Main Entrance

SAWYER SAMTDRIUM
White Daks Farm
Marian, Ohio

For the treatment of
Nervous and Mental Diseases
and Associated Conditions

Licensed for

The Treatment of Mental Diseases
by the Department of Public Welfare
Division of Mental Diseases
of the State of Ohio

Accredited by

The American College of Surgeons
Member of

The American Hospital Association
and

The Ohio Hospital Association

Hbusebook giving details, pictures,
and rates will be sent upon request.
Telephone 2140. Address,

SAWYER SANATORIUM
White Daks Farm
Marian, Ohio

Of course, where an employer sends his em-
ployee to a certain healer, whether he be a doctor
of medicine or not, and authorizes the healer to
perform certain services on the employee, then
the healer has the legal right to be compensated
for his services (290 Michigan, 397).

In an emergency, where life is in danger, an
employee may go to his own doctor — but a notifi-
cation to the employer is necessary if the healer’s
charges for his first service are to be recognized
by the employer or by his insurance company
(206 Michigan, 25 and 286 Michigan, 285).

To sum up, a medical director is under no legal
compulsion to refer an injured workman, at the
workman’s request, to a healer (other than the
doctor of medicine selected by the employer) for
care of injuries covered by the Michigan Work-
men’s Compensation Act.

MIUTARY MEMBERSfflP

Members of the Michigan State Medical So-
ciety in good standing for the year 1940 who are
called into active military service away from
home shall be relieved of the payment of State
dues during the period of such active service.
Members who have already paid their 1941 dues
and have since been called into active military
service away from home shall be accorded, upon
their return home, one year’s membership with-
out the payment of the State dues.

It is to be understood that such relief from the
payment of State dues can only be accorded phy-
sicians who have already been members of the
Michigan State Medical Society and who have
paid dues for at least one year.

Newly elected members since 1940 must pay
one year’s dues. Subsequent State dues will then
be waived during the period of such members’
active military service away from home.

"MALPRACTICE FEVER"

It is a recognized fact that when, in a given
locality, a malpractice action against a physician
has been decided in favor of the plaintiff, other
persons with grievances are spurred to action,
and, should there be an attorney in the locality
who is “in the market’’ for business of this kind,
an epidemic of suits against physicians is likely
to result. Unquestionably, the best defense
against such suits is their prevention. — Samuel
Wright Donaldson, A. B., M. D., F. A. C. R.
The Roentgenologist in Court. Charles C. Thom-
as, 1937.

392

Say you saw it in the Journal of the Michigan State Medical Society

JoxTR. M.S.M.S.

MICHIGAN’S DEPARTMENT OF HEALTH

HENRY A. MOYER, M.D., Commissioner, Lansing, Michigan

NEW LOW DEATH RATES

New low Michigan death rates per 100,000 popula-
tion were written in 1940 for pneumonia and tubercu-
losis, among the ten leading causes of death, and also
for typhoid and diphtheria, which a generation ago
were in the state’s big ten.

High and low rates and death totals over the last
forty years are :

Pneumonia — 1940 rate 47.15, deaths 2,478. Pre-
vious rates: lowest 53.75 in 1939, highest 210 in
1918. Previous death totals: lowest 2,276 in 1909,
highest 7,238 in 1918.

Tuberculosis — 1940 rate 33.35, deaths 1,753. Pre-
vious rates: lowest 36.07 in 1939, highest 107.15 in
1904. Previous death totals: lowest 1,881 in 1939,
highest 3,612 in 1900.

Diphtheria — 1940 rate .40, deaths 21. Previous
rates: lowest .48 in 1939, highest 25.20 in 1921.
Previous death totals: lowest 25 in 1939, highest
954 in 1921.

Typhoid — 1940 rate .19, deaths 10. Previous rates:
lowest .48 in 1939, highest 34.03 in 1900. Previous
death totals: lowest 25 in 1938, highest 824 in 1900.

One smallpox death was reported in 1940, that
of a sixty-five-year-old man. Michigan had no
smallpox deaths in 1939 and previously there had
been six years without a death.

Scarlet fever deaths in 1940 dropped to 41 and
a rate of .78, both new lows. A decline in virulence
of the organism is considered the explanation for
the low number of deaths. The worst scarlet fever
year of the last forty was in 1917, when there were
340 deaths.

PNEUMONIA DEATHS DROP
In the three years that pneumonia treatment in
Michigan has been generally changed by the use of
sulfonamide drugs and by serUms, pneumonia deaths
in the state have been cut 25 per cent.

The average for the years 1938, 1939 and 1940 is
2,717 deaths, which compares with 3,613 for the previ-
ous ten years and 3,592 for the previous five. There
was, then, an average of approximately 900 fewer
deaths per year during the past three years than
during the preceding five or ten year periods.

The drop in pneumonia deaths in 1940 over 1939
is 325, and some part of this reduction may be credited
to therapy with serums and with sulfapyridine and
sulfathiazole.

(DUE TO NEISSERIA GONORRHEAE)

ciTi

ilver Picrate,
Wyeth, has a convincing record of
effectiveness as a local treatment for
acute anterior urethritis caused by
Neisseria gonorrheae.^ An aqueous
solution (0.5 percent) of silver pic-
rate or water-soluble jelly (0.5 per-
cent) are employed in the treatment.

Acomp/ete technique of treatment and literature will be sent upon request

^Silver Picrate is a definite crystalline compound of silver and picric acid.
It is available in the form of crystals and soluble trituration for the prepara-
tion of solutions, suppositories, water-soluble jelly, and powder for vaginal
insufiSation.

1. Knight, F., and Shelanski,
H. A., "Treatment of Acute Ante-
rior Urethritis with Silver Picrate,”
Am. J. Syph., Gon. & Ven. Dis.,
23, 201 (March), 1939.

JOHN WYETH & BROTHER, INCORPORATED, PHILADELPHIA

May, 1941 393

Say you saw it in the Journal of the Michigan State Medical Society

MICHIGAN’S DEPARTMENT OF HEALTH

T7e could quote you paragraph upon para-
graph regarding the superb efficiency of
Coramine, “Ciba” as a circulatory and
respiratory stimulant. We could cite numer-
ous passages regarding speedy action, high
tolerance and wide margin of safety
from the vast bibliography published on
Coramine.* But it is our belief that only
actual use can convince you of the great
potentialities of this useful drug.

CORAMIIVE

(diethyl amide of nieotinic acid), is the
original, genuine product manufactured
exclusively by Ciba, and easily identified
by its crystal-white clearness. It has proven
its stimulating ability in . . . accident cases,
pneumonia, asphyxia, surgical shock,
selected cases of cardiac involvement and
other collapse states. . . . Large doses are
advisable in severe poisonings. Why not
request literature?

*Trade Mark Reg. U. S. Pat. Off. Word “Cora-
mine” identifies the product as the diethyl
amide of nicotinic acid of Ciba’s manufacture.

CIBA PHARMACEUTICAl PRODUCTS, INC.

SUMMIT • NEW JERSEY

On a national scale, the outstanding public health
netvs for 1940 has been declared to be a large re-
duction in the pneumonia death rate, as forecast by
insurance company studies. In Michigan, a reduc-
tion in the pneumonia death rate is also of major
importance. The rate for the ten years 1928-37
was 72 deaths per 100,000 population. During the
past three years the rate has been about 50 a re-
duction of one-third.

FREE SULFATHIAZOLE

Starting in April, sulfathiazole will be added to
the drugs and supplies distributed free to physi-
cians by the Michigan Department of Health for
treatment of venereal disease. Sulfathiazole is the
first drug distributed generally for treatment of gon-
orrhea.

As with other drugs for treatment of venereal
disease, - the sulfathiazole will be distributed in the
usual manner by the State Health Department in
unorganized territory and by county and district
health departments elsewhere after a case of gonorrhea
has been reported and request made for the drug.
Enough sulfathiazole is sent for one patient to give
what is considered a therapeutic course — 60 grains a
day for five days. The tablets are 7^ grains, 40
tablets to the bottle.

Drugs and materials now distributed by the De-
partment to physicians for treatment of venereal dis-
ease include : neoarsphenamine, mapharsen, trisodarsen,
bismuth subsalicylate, distilled water, and sulfathiazole.

NEW ACTING DEPUTY
COMMISSIONER

Dr. Carleton Dean, Deputy Commissioner of the
Michigan Department of Health and director of the
Bureau of Local Health Service since January 1,
1940, has been appointed medical director of the Mich-
igan Crippled Children’s Commission. Dr. Dean re-
signed effective April 1, to take his new position on
that date. His offices will be in Lansing in the Hollis-
ter building.

Dr. Dean is a former member of the State Coun-
cil of Health and a past president of the Michigan
Public Health Association. He joined the Depart-
ment staff from a district health department posi-
tion, coming to Lansing from Charlevoix where he
had been director for ten years of District Health
Department No. 3.

Promotion of Dr. E. V. Thiehoff to be Acting Dep-
uty and also to be director of the Bureau of Local
Health Services was announced shortly after Dr.
Dean’s resignation.

The advancement of Dr. Thiehoff came just a year
after he had joined the Department staff, also from a
district health department position. Dr. Thiehoff was
the first director of District Health Department No. 7,
comprising Gladwin, Clare, and Arenac counties. He
served the district from 1935 until April 1, 1940, when
he was appointed assistant to Dr. Dean.

Dr. Thiehoff entered public health work in 1925.
He has a master’s degree in public health from Johns
Hopkins University. His first work in public health
was as assistant director of the Bureau of Child H}’-
giene of the Missouri Board of Health. After a year,
he was named city physician in the Akron, Ohio, health
department, and later chief of the child l^giene serv-
ice there. In 1932, he was named acting director
of the Cleveland Child Health Association. He
served there until 1934, when he went to Vienna to
study.

Since January 27, he has been making appraisals
of county and district health departments.

Jour. M.S.M.S.

394

Say you saw it in the Journal of the Michigan State Medical Society

>f W^oman^s Auxiliary

This is the Last Call for reservations for the Nine-
teenth Annual Convention of the W oman’s Auxiliary"
to the American ^Medical Association which will be held
at Hotel Carter in Cleveland, June 2-6. All Cleveland
extends a hearty welcome to 3’ou !

Ingham County

In Februarj', the Ingham County Auxiliary" held its
annual dessert bridge part>' at the home of Mrs. Harry
Prall in East Lansing.

iMrs. H. A. Miller our social chairman, recently re-
turned from Mexico, brought beautiful bridge prizes
tj-pical of the country’. Mrs. Horace French, State Treas-
urer, and one of Lansing’s foremost bridge experts, had
the high score for the afternoon. Others winning the
loveh- ^klexican gifts Avere iMrs. L. G. Christian, !Mrs.
F. Mansell Ehmn and Mrs. F. C. Swartz.

At the business meeting we discussed the coming
month of April in regard to the drive for the control
of cancer, and we shall tr\' to enroll everj’ one in the
Ingham Count}’ Auxiliar}’ as a member of the W’^omen’s
Field Army for the Control of Cancer and thus every
individual subscribing can be assured of a small part in
this important work.

^Irs. Cameron iMurdock, a j’oung woman who has
just returned from a j’ear in Tahiti, discussed the effect
of the present war upon the island, at our April meet-
ing.

Margaret S. Davenport.

Jackson County

The regular monthly meeting of the iMedical Auxil-
iar}- to the Jackson Count}' Medical Society was held at
the Hayes Hotel, iMarch 18th at 6:30 p. m. After a
short business meeting Mrs. \Y. A. Whckham gave a
very interesting report on the work now being carried
on by the Project Committee. At the present time the
Committee is helping an eight-year-old boy from a
broken home, who is in need of medical aid.

The committee in charge of this meeting were Mes-
dames Don Kudner, W'^. R. Finton, Ray Newton, W\ A.
W ickham, Phil. Riley, J. C. Scott and C. A. Leonard.

After the meeting the thirty members and guests ad-
journed to the High School as guests of the W’oman’s
Club to hear Henry C. W^olfe, foreign correspondent
and lecturer.

Kent County

The regular monthly meeting of the W’oman’s Auxil-
iary to the Kent County Medical Society was held
March 12 in the Public iVIuseum Auditorium.

Follow'ng the business session, Mrs. Fred C. Brace,
gave a most interesting discussion and reading of four
of Eugene O’Neill’s one-act plays which were used in
the motion picture “The Long Voyage Home.”

On April 3 the Auxiliary, in conjunction with the
League for the Control of Cancer, sponsored a free
open meeting ‘n the Museum Auditorium. An instruc-

Detroit Clinic and Alnmni Hennion

of

—y4lumni ^^diociation of '\^aune Coiie^e of WJicine

Wednesday, June 11, 1941

9:00 A.M. — Registration.

Morning Lectures — Detroit Institute of Arts
Woodward at Kirby

Business Meeting.

12:15 P.M. — Buffet Luncheon, Wayne County Medical Society.

Afternoon Lectures — Detroit Institute of Arts

5:30 P.M. — Cocktail Hour — on your own.

7:00 P.M. — Annual Banquet and Class Reunions — Hotel Statler
Malcolm Bingay — Toastmaster — Entertainment.

Speaker: Wallace R. Deuel

Ace Foreign Correspondent, Chicago Daily News

N. B. Ladies are imdted to the Banquet.

FURTHER DETAILS WILL EE LURNISHED EY MAIL

May, 1941

Say you saiv it in the Journal of the Michigan State Medical Society

395

WOMAN’S AUXILIARY

tive film was shown and Dr. O. H. Gillett gave a talk
on “Cancer Control.’’

Our next meeting is our Annual Tea, which is al-
ways a highlight of the year. Mrs. Reuben Maurits is
extending the hospitality of her home for the event,
and Mrs. David B. Davis is planning the musical pro-
gram.

Elizabeth Van Bree.

Monroe County

The Auxiliary to the Monroe County Medical Society
met at the home of Mrs. M. A. Hunter, on February
18 at which twelve members were present. After a
short business meeting refreshments were served and
the members sewed for the Red Cross.

The Auxiliary met at the home of Mrs. H. W. Lan-
don for its March meeting and had as guest speaker,
Mrs. J. L. Wierengo of Grand Rapids, who spoke on
cancer control.

There were twelve members present and after re-
freshments were served they sewed for the Red Cross.

Genevieve A. Reiseg.

Saginaw County

Tschaikowsky’s Fifth Symphony was the topic of
discussion at the Saginaw County Medical Auxiliary’s
monthly meeting on Tuesday evening, March 18, at the
home of Mrs. Fred. J. Cady, Saginaw. Mrs. Rockwell
M. Kempton, program chairman, presented Mrs.
Charles C. Coulter, who read a paper on the life of
Tschaikowsky ; and Miss Leona A. Rohde, who ana-
lyzed the Symphony. Mrs. Coulter and Miss Rohde are
active members of the Tuesday Musicale.

Refreshments were served after the meeting at an
attractive table decorated with white spring flowers and
white tapers. Mrs. W. J. O’Reilly and Mrs. J. W.
Hutchison poured.

Mrs. D. C. Durman was in charge of the social hour
assisted by Mrs. Eugene A. Hand, Mrs. H. J. Richter,

Mrs. H. M. Bishop, Mrs. H. B. Kleekamp, Mrs. J. P.
Markey and Mrs. H. E. Mayne, all of Saginaw, and
Mrs. F. W. Ostrander, of Freeland.

Shiawassee County

The Woman’s Auxiliary to the Shiawassee County
Medical Society was organized September 19, 1940, with
the able assistance of Mrs. L. G. Christian, State Legis-
lation Chairman. The club is active and the meetings
well attended. They sponsored one lecture given by
Dr. L. F. Foster on “New Conceptions of Health In-
surance,’’ January 9, in the Woman’s Club and W. J.
Burns, executive secretary of the State Medical Society,
gave a very interesting talk on State Legislation March
25.

Cora Watts.

Wayne County

The March meeting of the Woman’s Auxiliary to the
Wayne County Medical Society was held on Friday,
March 14, at the Society’s headquarters.

Dr. J. Milton Robb introduced the speaker of the
day, Mr. John M. Pratt, Executive Administrator of
the National Physicians Committee for the Extension
of Medical Service.

Mr. Pratt spoke on “Medical Legislation.’’ He dis-
cussed the tremendous advancement of medicine in the
last century and emphasized the fact it was made pos-
sible by the underlying principle of freedom in this
country. He pointed out that the United States has the
highest standards of health and the lowest death rate
which the world has ever known, and he urged the
continued operation of a system which had made such
progress possible.

Following the address, Mrs. Buesser, president of the
Auxiliary, appointed a Committee to study Mr. Pratt’s
message, consider suggestions and formulate a program
for future action.

Tea was served at the conclusion of the meeting.

Margaret J. Wallace.

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396

Say you saw it in the Journal of the Michigan State Medical Society

Jour. M.S.M.S.

IN MEMORIAM

jUcinnriatn

1 LaMotte F. Bates of Durand was born August 19,
) 1901 in Durand, and was graduated from the Durand
i High School June 1918.

He entered the University of Michigan and was
graduated from the University of Michigan Medical
School in 1924. He served his internship in Detroit,
in the Durand Hospital and in Memorial Hospital,

. then entered active practice with his uncle, the late
, R. C. Fair, M.D. During the years that followed
I Doctor Bates built a large practice and became one
of the leading physicians of Shiawassee County. For
( some years he had been surgeon of the Grand Trunk
railroad. Doctor Bates served as president of Shia-
, wassee County Medical Society in 1940. He died
as the result of a fall, April 5, 1941.

George Clinton Hafford, of Albion was born July
1 10, 1862, in Pierpont Manor, New York and was
graduated from the University of Michigan Medi-
cal School, June 30, 1887. After a year of practice
in Carleton, Michigan, he went to Manistique for
ten years’ service. In 1899 Doctor Hafford returned
to lower Michigan and located in Albion, which had
i been his home until the time of his death. For the
last twenty-three years his associate has been his
; son, Alpheus T. Hafford, M.D. Doctor Hafford
gained the rank of major in the World War while
serving as surgeon in the Medical Corps at Fort
Benjamin Harrison, Indiana, Camp Taylor, La., and
as chief surgeon in a 3,000 bed hospital in Fort
McHenry, Md. He was elected Emeritus Member
i of the Michigan State Medical Society in 1938 and
an Affiliate Member to the American Medical Asso-
ciation in 1939. Doctor Hafford was active in the
Michigan State Medical Society, serving as Coun-
cilor of the Third District for six years. He was
also interested in the activities of the American
Legion and many civic organizations. He died April
19, 1941, in St. Petersburg, Florida.

James J. Haviland of Owosso was born near
Gaines, Michigan on March 25, 1869, attended and
graduated from Gaines High School, and then ent-
ered the .Detroit College of Medicine, receiving his
degree in medicine in 1894. The following year he
started practicing in Lennon. Later he took post-
graduate courses at the University of Michigan, and
in New York, then resumed his Lennon practice
in 1899. Still later he spent six months at the Royal
Hospital, London, England. In 1910 Doctor Havi-
land came to Owosso and practiced there until his
death, with the exception of the time spent in the
army during the World War. He enlisted in 1917
in the Medical Corps of the 329th Field Artillery of
the 85th Division, and in June 1918, went overseas
until March 1919, when he returned and was hon-
orably discharged at Camp Grant, with the rank
of major. A short time later he was commissioned
a colonel in the reserve corps and placed on the in-
active list. Doctor Haviland died March 25, 1941.

Charles H. Heffron of Adrian was born in 1871 in
Fulton county, Ohio. He attended Adrian high
school and in 1893 completed a course in medicine
at Western Reserve (Wooster) University. Later
he took a postgraduate course at the University of
Michigan. He began his career as a physician in
Metamora, Ohio in 1893 and for a period of some 27
years practiced there. Doctor Heffron went to
Adrian, Michigan in 1920, and established his prac-
tice which he continued until his death on March
22, 1941.

May, 1941

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r IS IT TRUE THAT
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LIBBY'S HOMOGENIZED
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As demonstrated in this
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Say you saw it in the Journal of the Michigan State Medical Society

397

IN MEMORIAM

Albert G. Huegli of Detroit was born September
4, 1878 in Detroit, Michigan and was graduated
from the Detroit College of Medicine in 1901. Since
graduation, he conducted a practice in Detroit. With
the founding of Deaconess Hospital, Doctor Huegli
became an interested and industrious member of the
Medical Staff, serving for twenty-two years, until
his death, as secretary of that organization. Besides
his work on the Deaconess staff. Doctor Huegli was
attending physician of the Evangelical Lutheran
Institute for the Deaf. He was well known as a
progressive internist. Doctor Huegli died March 7,
1941.

Francis H. Husband of Sault Ste. Marie was born
in Welreby, Ontario, Canada, July 13, 1877 and
was graduated from the University of Michigan
School of Medicine in 1901. For a brief period after
graduation he was in Port Huron, Michigan. Then
he moved to Sault Ste. Marie in 1902, where he
established his practice and remained, except for
periods of postgraduate work in the east. Doctor
Husband served as president of Chippewa County
Medical Society in 1930. He died March 16, 1941.

William A. Royer of Battle Creek was born June
15, 1864 in LaGrange County, Indiana, and was
graduated from LaGrange High School. After at-
tending normal college in Wauseon, Ohio, he taught
school for several years and then enrolled in the
University of Michigan Medical School. He was
graduated from the University in 1892. Doctor
Royer practiced twenty-two years in Mendon,
Michigan, one year in Fulton and three years in
Sturgis and had maintained offices in Battle Creek
for twenty-three years. He died March 30, 1941.

George P. Sackrider of Owosso, Michigan was
born May 4, 1874 in Oakley, Michigan and was grad-

uated from the Detroit College of Medicine. Folj
lowing graduation, he served as an interne at Harp?
er Hospital, Detroit, and in 1905 located in Hender?
son, Michigan where he practiced until 1912. He
moved to Owosso in 1912 and continued the practice
of general medicine and surgery. When the United
States entered war in 1917 Doctor Sackrider gave'
up his practice and enlisted in Base Hospital Unit
No. 36, the second outfit to go overseas. He spent
twenty months in the army, being discharged with"
the rank of major. Returning to Owosso after the
war. Doctor Sackrider in 1920 started specializing
in treatment of the eye, ear, nose and throat and
continued in that practice until his death. He died
March 11, 1941. J

Cyril K, Valade of Detroit was born in that city
March 27, 1891, and was graduated from Central
High School and the Wayne University College of
Medicine in 1916. Doctor Valade volunteered his
services in the English Army in the World War, and
was at Graylingwell Hospital, and later transferred
to Charing Cross Hospital, and also was stationed
at St. Bartholomew’s in London, England. He was
transferred to the American Army after the United
States entered the war and was stationed at Roch-
ester Row Hospital. He was honorably discharged
as a Captain of the United States Medical Corps.
Dr. Valade was affiliated with various Veteran’s
Societies, and a Past Commander of the Business
and Professional Men’s Post, American Legion, and
at the time of his death was Chairman of the
Syphilis Control Committee of the Michigan Medi-
cal Society. He specialized in Dermatology and
had published several books on the subject. He
was a member of the staff of Receiving, St. Joseph’s
Mercv and Harper Hospitals. Doctor Valade died
March 27, 1941.

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398

Say you saw it in the Journal of the Michigan State Medical Society

Jour. M.S.M.S.

-X COUNTY AND PERSONAL ACTIVITIES -X

100 Per Cent Club for 1941

Allegan

Barry

Clinton

Dickinson-Iron

Eaton

Huron

Ingham

Jackson

Lapeer

Lenawee

Luce

Manistee

Menominee

Muskegon

Ontonagon

St. Clair

Sanilac

Tuscola

Wexford-Missaukee

The above county medical societies have certified
the 1941 dues of 100 per cent of their member-
ship.

Eleven county societies are not in “The 100 per
cent club” because of only one delinquent mem-
ber! Eighteen other county societies have less
than five delinquent members.

Warren E. Wheeler, M. D., Field Representative in
Pediatrics, addressed the Barry County Medical So-
ciety at its meeting of April 10th in Hastings.

^

W. H. Huron, M. D., Iron Mountain, addressed the
Woman’s Auxiliary to the Marquette-Alger County
Medical Society at its meeting of April 2nd.

* #

Councilor Ray S. Morrish, M. D., Flint, attended the
National Convention of the American Red Cross in
M^ashington the week of April 21st.

Members of the Public Health and Venereal Control
Committee of Macomb County Medical Society are
W. J. Kane, M. D., E. J. Dudzinski, M. D., and R.
E. Lynch, M. D.

Frank Stiles, M. D., Lansing, addressed the lonia-
Montcalm County Medical Society at Portland on May
13 on the subject of “Skin Diseases and Treatment of
Same,” illustrated by lantern slides.

^ ^ ^

The American Association for the Study of Goiter
held its 1941 meeting at the Hotel Statler, Boston, on
May 12-14. The program for the three-day meeting
consisted of papers dealing with goiter and other dis-
eases of the thyroid gland, dry clinics and demon-
strations.

=is * *

A one-day conference some time in June on Student
Health Practice is being arranged for physicians and
others interested in this work. Address inquiries con-
cerning plans for the conference to Dr. Claire E.
Healey, University Health Service, University of
Michigan, Ann Arbor, Michigan.

^ ^ ^

Frank H. Power, M. D., Ann Arbor, formerly field
representative in Cancer for the Michigan State Medi-
cal Society has been called for active service with the
Army and is now stationed at Fort Jackson, South
Carolina. As yet, no successor has been appointed in
place of Doctor Power.

i "■ ' ' ^

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May, 1941

Say you saw it in the Journal of the Michigan State Medical Society

399

COUNTY AND PERSONAL ACTIVITY

I

Ferguson -Droste- Ferguson Sanitarium

♦

Ward S> Farffuson, M. D. Jamas C. Drosta, M. D. Ljmn A. Farcuaon, M. D.

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♦

' Sanitarium Hotel Accommodations

New address. Captain L. A. Potter, Inspector for the
State Health Department, reports that George Saxton,
a layman, formerly of Allegan, was sentenced on April
1st to two to four years in Jackson Prison for per-
forming illegal abortions. Mr. Saxton was also fined
$500 in Circuit Court by Judge Fred T. Miles.

* * *

Arthur R. Woodhurne, M. D., Grand Rapids, has
been appointed Chairman of the M. S. M. S.
Syphilis Control Committee by President P. R. Urm-
ston to fill the vacancy due to the death of C. K.
Valade, M. D. Doctor Urmston also appointed Eu-
gene Hand, M. D., of Saginaw to the Syphilis Control
Committee.

♦ ♦ *

L. Femald Foster, M. D., Bay City; Roy Herbert
Holmes, M. D., Muskegon; T. E. Hoffman, M. D.,
Vassar; Hewitt Smith, M. D. and Harold A. Miller,
M. D., Lansing, addressed a meeting of the Kent Coun-
ty Medical Society in Grand Rapids on April 17th.
“Medical Care of Welfare Clients” was the subject of
The Symposium.

=|! * *

The Kalamazoo Academy of Medicine has entered
into a contract with the Kalamazoo County Social Wel-
fare Board to provide home and office medical care to
those on welfare in Kalamazoo County, to be effective
as of June 1, 1941. The Kalamazoo Social Welfare
Board also executed a separate contract to provide
hospitalization for welfare cases.

♦

Bowlers attention! Plans are on foot to have a
bowling tournament during the 1941 session of the
American Medical Association in Cleveland the week
of June 2nd. It is hoped that teams can be formed

representing various states. Physicians interested in
bowling please write Lewis W. Bremerman, M. D.,
1709 West 8th Street, Los Angeles, California.

* ♦ ♦

“Electric Arc Welding : The Effects of Welding
Gases and Fumes” appeared in 4he issue of April 12,
1941, written by Stuart P. Meek, M. D., Carey P. Mc-
Cord, M. D., and Gordon C. Harrold, Ph.D., all of De-
troit.

“Mass Testing of Color Vision” by Erich Sachs, M.
D., Detroit, appeared in the issue of April 19th.

♦ ♦ ♦

The 43rd Annual Meeting of the Medical Library
Association will be held at the University of Michigan
Medical School, Ann Arbor, on May 29-31, 1941, under
the presidency of Col. Harold W. Jones, of the Army
Medical Library, Washington, D. C. The program
will include papers on the Cooperation of Libraries,
Union Catalogs, Medical History and Industrial Medi-
cine.

♦ * *

Volunteers are needed for the Royal Army Medical
Corps and Emergency Medical Service. According to
the American Red Cross at least 1,000 young American
doctors of medicine are needed in Britain to help
care for the civilian population as well as service with
the Royal Army Medical Corps. Applicants must be
citizens of the United States, unmarried or without de-
pendents, and no more than forty years of age for
service with the RAMC, and no more than forty-five
years old for appointment to the Emergency Medical
Service. For ftill information as to qualifications and
other details, write the American Red Cross National
Headquarters, Washington, D. C.

400

Say you saw it in the Journal of the Michigan State Medical Society

Jour. M.S.M.S.

if in ^ ^

COUNTY AND PERSONAL ACTIVITY

Recent articles written by members of the Michigan
State Medical Society and published in The Journal of
the American Medical Association include the follow-
ing:

“Diseases of the Respiratory Tract and Air Condi-
tioning” by Carey P. McCord, M, D., Detroit, issue of
March 29. “Diagnosis of Injuries of the Hand” by J.
M. Winfield, M. D., Detroit, appeared in the same is-
sue.

♦ ♦ ♦

Civil Service applications are being received for sen-
ior medical officers at $4,600 per year; medical officers
at $3,800 ; and associate medical officers at $3,200. These
appointments are available in the Public Health Serv-
ice, Food and Drug Administration, Veterans’ Admin-
istration, Civil Aeronautics Administration, and Indian
Service. Applications should be filed with the United
States Civil Service Commission, Washington, D. C.,
as early as possible.

♦ * ♦

Physicians are urged to refrain from collecting phar-
maceutical samples for shipment to British Relief. It
is pointed out that while we may all be in s}unpathy
with the “Bundles for Britain” movement, this particu-
lar practice is very expensive and the value to the
British is questionable due to the heterogenous mate-
rial which reaches the British Relief. In addition,
most all of the pharmaceutical manufacturers have in-
dividually donated large supplies of vitamin capsules
and other needed pharmaceutical products to the Brit-
ish Relief at no charge.

* * ♦

Doctor, remember your particular friends, the ex-
hibitors, at your annual convention, when you have
need of equipment, appliances, medical supplies and
service. Here are ten more of the firms which helped
make the 1940 convention such a success :

Gerber Products Company, Fremont.

General Electric-X-Ray Corporation, Chicago.

H. G. Fischer & Company, Chicago.

Ehike Laboratories, Inc., Stamford, Connecticut.

Detroit X-Ray Sales Company, Detroit.

R. B. Davis Company, Hoboken, New Jersey.
Cottrell-Clarke, Inc., Detroit.

The Coca-Cola Company, Atlanta, Georgia.

S. H. Camp & Company, Jackson.

Cameron Surgical Specialty Company, Chicago.

:(: * *

The Oakland County Medical Society were guests
of Mr. Harry J. Klingler, General Manager of Pontiac
Motor Division, on May 14 when they visited the new
Pontiac Plant Hospital. Members of the Society were
shown through the completely new hospital bv Ethan

B. Cudney, M. D., Pontiac’s medical director. Guest of
honor at the hospital and plant tour and dinner were

C. D. Selby, M. D., medical consultant for General
Motors Corporation. Following the dinner in the
plant restaurant, Kenneth E. Markuson, M. D., Di-
rector of the Bureau of Industrial Hygiene of the
Michigan Department of Health, spoke on “The Rela-
tionship of the Private Physician, the Industrial Phy-
sician and the Bureau of Industrial Hygiene to In-
dustrial Health.”

* * *

The Michigan Association of Industrial Physicians
and Surgeons held its 1941 Annual Meeting in Detroit
on April 16th. Among the distinguished speakers on
the program were Edward C. Holmblad, M. D., Chi-
cago; John Sundw^ll, M. D., Ann Arbor. J. Harold
Couch. M. D., Toronto ; Daniel J. Lynch, M. D., Bos-
ton; E. S. Gurdjian, M. D., Arthur E. Schiller, M.

D. , Wm. A. Lange, M. D., Frank A. Kelly, M. D.,
Wm. E. Blodgett, M. D., George P. Myers, M. D.,

E. Howard Hanna, M. D., Walter G. Paterson, M. D.,
Wm. Y. Kennedy, M. D., A. Willis Hudson, M. D.,
Earl G. Kriee. M. D., Earl F. Lutz, M. D., Charles
H. Clifford, M. D., Clyde K. Hasley, M. D., Herbert
H. Holman, M. D., John A. Hookey, M. D., Harold

May, 1941

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Say you sazt^ it in the Journal of the Michigan State Medical Society

401

COUNTY AND PERSONAL ACTIVITY

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The Wassermann and Kahn Tests

Blood Chemistry

Bacteriology and Clinical Pathology

Basal Metabolism

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Electrocardiograms

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A. JAMES DeNIKE, M.D.

Medical Superintendent

K. Shawan, M. D., Carey P. McCord, M. D., Frank
T. McCormick, M. D., John J. Prendergast, M. D.,
Harry Miller, M. D., Clarence D. Selby, M. D., Frank
Koss, M. D., Francis MacMillan, M. D., Clarence Ma-
guire, M. D., A. H. Whittaker, M. D., Grover C.
Penberthy, M. D., Charles S. Kennedy, M. D., and E.
F. Collins, M. D., all of Detroit.

♦ ♦ ♦

Mark Your Calendar Now! September 17, 18, 19,
are red letter days for you. Plan to attend the 1941
Grand Rapids Convention of the Alichigan State Medi-
cal Society. Thirty outstanding leaders in scientific
medical progress have accepted invitations to speak in
Grand Rapids next September. The list will be pub-
lished in the June Journal. Don’t miss this unpar-
alleled opportunity to hear these national and inter-
national authorities discuss first-hand the problems
which confront you every day in your practice.

Opportunity will be given for round table discussion
led by these men at 3:30 each afternoon.

Spend September 17, 18, 19, 1941, in Grand Rapids.
And bring your wife. She will enjoy the activities and
entertainment arranged by the Woman’s Auxiliary. It's
not too soon to write for hotel reservations !

* * *

In March and April of this year the Macomb Coun-
ty Medical Society undertook the immunization of all
the school children of the county against diphtheria
and smallpox. Two doses of toxoid, a month apart,
were given all applicants up to and including the age
of ten, after which all who applied were vaccinated.
Hitherto the urban population had been protected year-
ly, but this was the first attempt at rural immunization
and the response obtained proved the urgent need.

Thirty-five physicians donated their time to this cause
and St. Joseph Hospital of Mt. Clemens gave the
services of thirty student nurses to aid at the clinics.
Twenty-one centers were established in schools

throughout the county and the children from the sur-
rounding districts were transported thereto. Twenty-
five cents per treatment was the fee for those who
could afford it. All others were treated free. The
fees were collected by the local teachers and the in-
dividual schools were allowed to keep them to spend
in any manner they saw fit. Between 7,500 and 8,000
treatments were administered and the Society plans to
make this an annual program.

* * *

Alumni Clinic and Reunion
The Annual Clinic and Reunion of the Alumni As-
sociation of Wayne University College of Medicine

will be held Wednesday, June 11, 1941, 10:00 to 5:00
P. M., Detroit Institute of Arts, Woodward at Kirby,
Detroit. Speakers will be :

Wm. Magner, M.D., D.P.H., Professor of Pathology,
University of Toronto : “The Pathogenesis of Anemia.”
Phillip Dudley Woodbridge, M.D., New Haven,

Connecticut, formerly of Lahey Clinic: “Recent De-
velopments in Anesthesia.”

Frank D. Dickson, M.D., Kansas City: “The Surgical
Treatment of Arthritis.”

Charles W. Mayo, M.D., Mayo Clinic: “Malignancy
of the Lower Colon and Rectum, Surgical Treatment.”
Walter L. Palmer, M.D., Department of Internal
Medicine, University of Chicago : “Diagnosis and

Treatment of Gastric Disease.”

Wallace R. Deuel, ace foreign correspondent of the
Chicago Daily News, will be guest speaker at the Ban-
quet. His subject will be “World Counter-revolution.”
The Executive Committee of the Association is
composed ot the iollowing:

W. W. McGregor, M.D., President; C. E. Umphrey,
M.D., President-Elect; Volney Butler, M.D., Secretary;
C. H. Eisman, M.D., Treasurer; Harold Kullman, M.D.,
Harold Sawyer, M.D., L. P. Pratt, M.D., Louis J.
Bailey, M.D., N. W. Woodry, M.D., P. L. Ledwidge,
M.D.

402

Say you saw it in the Journal of the Michigan State Medical Society

Jour. M.S.M.S.

COUNTY AND PERSONAL ACTIVITY

Bruce H. Douglas, M. D., took over his new duties
as Health Commissioner of Detroit on April 15, suc-
ceeding Henry F. Vaughan, Dr. P. H., recently ap-
pointed head of the new school of Public Health at
the University of Michigan. Doctor Douglas is prom-
jinent in the field of tuberculosis, having made a num-
ber of surveys on tuberculosis problems. He is on

Commissioner Douglas

the teaching staff of the University of Michigan and
Wayne University and is a member of the National
, Research Council Committee on Tuberculosis. He is
a past president of the American Sanatorium Associa-
' tion, the Mississippi Valley Conference on Tuberculo-
i sis, the Michigan Trudeau Society and the Michigan
i Tuberculosis Society. At the same time, the Detroit
[ Board of Health announced the appointment of Jo-
seph G. Molner, M. D., as Deputy Health Commission-
er and Medical Director ; and Garner M. Byington, M.
D., Dr. P. H., as Director of Child Welfare and School
Health Service.

I ^ ^

The MSMS Radio Committee advises that the fol-
\ lowing Health Talks were broadcast over radio sta-
: tion CKLW :

Saturday, March 1 — “Feeding the New Baby” by
I Wilfred S. Nolting, M. D., Detroit.

Saturday, March 8 — “Appendicitiis” by Clifford D.
Benson, M. D., Detroit.

Saturday, March 15 — “Can Cancer Be Cured” by
i Harry Nelson, M. D., Detroit.

Saturday, March 22 — “The Value of Anesthesia in
[ Surgery and Medicine” by Norman Bittrick, M. D.,

I Detroit.

' Saturday, March 29 — “Problems in Obesity” by

Richard Connelly, M. D., Detroit.

Saturday, April 5 — “Anemia” by Neil J. Whalen,

. M. D., Detroit.

Saturday, April 12 — “Acute Abdominal Pain” by
Gaylord S. Bates, M. D., Detroit.

Saturday, April 19 — “Alisconceptions About Heart
Disease” by Ralph A. Johnson, M. D., Detroit.

This will conclude the radio talks sponsored by the
Michigan State Medical Society for the year 1940-41.

^ ^

Golfing Association Tournament

The American Medical Golfing Association’s Twen-
ty-Seventh Annual Tournament will be held at Cleve-
land Country Club-Pepper Pike Club, Cleveland, Ohio,
Monday, June 2, 1941. Two famous championship
courses and a beautiful clubhouse await the nation’s
medical golfers in Cleveland on the occasion of the
i A.M.A. Convention.

86c out of each $1.00 gross income
used for members benefit

PHYSIQANS CASUALTY ASSOCIATION
PHYSICIANS HEALTH ASSOCIATION

Hospital, Accident, Sickness

INSURANCE

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(56,000 Policies in Force)

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$10,000,000.00 PAID FOR CLAIMS

$200,000 deposited with State of Nebraska for pro-
tection of our members.

Disability need not be incurred in line of duty — benefits
from the be^nning day of disability.

Send for applications, Doctor, to

400 First National Bank Building Omaha, Nebrasko

LABORATORY APPARATUS

. Coors Porcelain

Pyrex Glassware
R. & B. Calibrated Ware
Chemical Thermometers
Hydrometers
Sphygmomanometers

J. J. Baker & Co., C. P. Chemicals
Stains and Reagents
Standard Solutions

• BIOLOGICALS •

Serums Vaccines

Antitoxins Media

Bacterins Pollens

We are completely equipped and solicit
your inquiry for these lines as well as for
Pharmaceuticals, Chemicals and Supplies,
Surgical Instruments and Dressings.

•7Ue RUPP & BOWMAN GO.

319 SUPERIOR ST., TOLEDO, OHIO

May, 1941

Say you sazv it in the Journal of the Michigan State Medical Society

403

COUNTY AND PERSONAL ACTIVITY

PftOFESSOHMPlKOirOOH

A DOCTOR SAYS:

“This has been an instructive ex-
perience and goes to show that past
friendly relations with a patient are
no guarantee of immunity against a
lawmit when a little easy money
appears possible.”

OF

Some 250 of the 1,413 Fellows of the A.M.G.A. are
expected to take part in this 36-hole competition. Each
contestant will play both courses. The hours for tee-
ing off are from 7 :30 a. m. to 2 ;00 p. m.

The sixty prizes, in the nine Events, will be dis-
tributed after the banquet at the Cleveland Country
Clubhouse at 7 :00 p. m.

Officers of the A.M.G.A, for 1941 are D. H. Hous-
ton, M. D., Seattle, president; Harry E. Hock, M. D.,
Chicago, and James Craig Joyner, M. D., New York
City, vice presidents; Bill Bums, secretary.

The Cleveland Golf Committee is composed of John
B. Morgan, M. D., Chairman, 1822 Republic Building;
William J. Engel, M. D., Farrell T. Gallagher, M. D.,
and F. W. Merica, M. D.

All members of the A.M.A. are eligible for Fel-
lowship in the A.M.G.A. Write the Secretary, 2020
Olds Tower, Lansing, Michigan, for registration ap-
plication.

* ♦ ♦

The Placement Bureau of the Michigan State Medi-
cal Society is eager to learn of the names of physicians
who are interested in finding locations in which to
practice. Every effort is being made by the Placement
Bureau to find locum tenens for physicians who arc
called to milintary service. Physicians who are inter-
ested in finding a locum tenens while they are away
in the Army or physicians who are looking for a place
in which to practice, are urged to write the Placement
Bureau, c/o 2020 Olds Tower, Lansing, Michigan.

404

Say you saw it in the Journal of

CLASSIFIED ADVERTISING

FOR RENT OR SALE — Deceased physician’s modern
home with double garage and three room office com-
bined. In small town on U. S. 131, 14 miles from
Kalamazoo, surrounded by prosperous farming com-
munity. Good school and roads. Fine hospitals and
laboratories available close by. Excellent opportunity
for an ambitious, general practitioner. Send inquiries
to Mrs. Edna I. Snyder, 500 W. Fullerton Pkwy.,
Chicago, Illinois.

FOR SALE: DeLuxe Ford Coupe, opera seats (new in
June 1940) with radio and heater. Box 15, The
Journal M.S.M.S., 2020 Olds Tower, Lansing,

Michigan.

WANTED — A physician with Michigan license to do
general practice during month of June and definite
period thereafter. Arrangements for personal inter-
view necessary. Salary $350.00 per month. Box 10,
Michigan State Medical Society, 2020 Olds Tower,
Lansing, Michigan.

Jour. M.S.^I.S.

the Michigan State Medical Society

THE DOCTOR’S LIBRARY

1

THE DOCTOR’S LIBRARY

Acknowledgement of all books received will be made in this
column and this will be deemed by us as a full compensation
of those sending them. A selection will be made for review,
as expedient.

HEMORRHAGIC DISEASES. Photo-Electric Study of Blood
Coagulability. By Kaare K. Nygaard, M.D., Former Fellow
in Surgery, the Mayo Foundation; Former Assistant Surgeon,
the University Clinic, Oslo; Fellow of the Alexander Malthe
Foundation for Research in Medicine, Surgery and Gyne-
cology. Illustrated. St. Louis: The C. V. Mosby Company,
1941. Price: $5.50.

Nygaard has added, in this beautiful monograph, a
great deal to the study of blood coagulability. This
work has been done through the new photelgraph
which automatically records such progressive process-
es as the coagulability of the blood and other phe-
nomena. The determinations are visualized by pho-
telgraphic tracings called coagelgrams. The classical
conception of the process of coagulation is that the
two phases ; first, the formation of thrombin, and
second, the transition of fibrinogen into fibrin has been
modified through this work since it was determined
that these two processes were telescoped one into the
other chronologically. Also, it was determined that
the velocity of the process of blood coagulation is a
relative expression of the velocity of thrombin for-
mation. These and other findings are applied clinical-
ly to the various diseases in which the coagulation
of the blood is of primary consequence. Such con-
ditions as hemophilia, thrombocytopenic purpura, the
action of vitamin K, diseases of the gallbladder, bile
ducts, pancreas and liver, hemorrhagic disease of the
new-born are all discussed in relation to these find-
ings. That this work was done at the Mayo Clinic
reflects greatly to the honor of that group.

4: « «

A DIABETIC MANUAL for the Mutual Use of Doctor and
Patient. By Elliott P. Joslin, M.D., Sc.D., Clinical Pro-

fessor of Medicine Emeritus, Harvard Medical School;
Medical Director, George F. Baker Clinic at the New

England Deaconess Hospital; Consulting Physician, Boston
City Hospital, Boston, Mass. Seventh Edition, thoroughly

revised. Illustrated. Philadelphia: Lea and Febiger, 1941.

Price: $2.00.

The old master of diabetes presents his .seventh
edition of this valuable adjunct to the care of the dia-
betic. It is very readable and, of course, scientifically
sound. There is a large question and answer divi-
sion which answers most of the questions which are
asked by the patient. The optimism of the book is
commendable. This is a perfectly safe and instruc-
tive book for the use of any diabetic.

* 4:

TEXTBOOK FOR MALE PRACTICAL NURSES. By Gayle
Coltman, R.N. New York: The MacMillan Company, 1941.
Price: $2.00.

This is a very detailed description of how to care for
the sick patient in the hospital by one not having tech-
nical training. The material in it seems applicable to
both male and female practical nurses and could be
studied by all these advantageously.

C^^ectix^, (Convenient
and SconomicaC

The eflFectiveness of Mercurochrome has been
demonstrated by twenty years’ extensive clinical use.

For the convenience of physicians Mercurochrome
is supplied in four forms — Aqueous Solution for
the treatment of wounds, Surgical Solution for
preoperative skin disinfection. Tablets and Powder
from which solutions of any desired concentration
may readily be prepared.

{dibrom-oxymercuri-fluorescein-sodium)

is economical because solutions may be dispensed
at low cost. Stock solutions keep indefinitely.

Mercurochrome is accepted by the
Council on Pharmacy and Chemistry of
the American Medical Association.

Eiterature furnished on request

HYNSON, WESTCOTT & DUNNING, INC.

BALTIMORE, MARYLAND

THE MASK OF SANITY. An Attempt to Reinterpret the
So-called Psychopathic Personality. By Hervey Qeckley, B.S.,
B.A. (Oxon.), M.D., Professor of Neuropsychiatry, University
of Georgia School of Medicine, Augusta, Georgia. St. Louis:
The C. V. Mosby Company, 1941. Price: $3.00.

The so-called psychopathic personality has always
been a headache to the family physician and a heart-
ache to the family and friends of the patient. In this
volume a number of cases are interestingly reported
and the viewpoint of the hospital and police authorities
is emphasized. The purpose is to better define and
interpret this condition and stimulate some coordination
between medical and legal authorities in handling these
unfortunates. This group cannot be confined in the
mental hospitals because they are sane and they can-
not be cared for in the penal institutions because of
their irresponsibilities. The general practitioner who
reads this book will have a better understanding of
these cases.

jK 4: *

MANUAL OF CLINICAL CHEMISTRY. By Miriam Reiner,
M.Sc., Assistant Chemist to the Mount Sinai Hospital, New
York. Introduction by Harry Sobotka, Ph.D., Chemist to the
Mount Sinai Hospital, New York. With 18 illustrations. New
York: Interscience Publishers, Inc., 1941. Price: $3.00.

A compact pocket-sized edition which does very
well in covering practical biochemistry. It is a com-

ZEI>1 IVICR

Prescribe or dispense ZEMMER pharmaceu-
ticals . . . laboratory controlled . . . guaran-
teed reliable potency.

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Write for general price list.

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THE ZEMMER COMPANY^^

May, 1941

405

Say you saw it in the Journal of the Michigan State Medical Society

THE DOCTOR’S LIBRARY

pilation of the methods used at Mount Sinai Hospital
in New York. It is very practical, giving in detail the
procedures and techniques. The determination of vita-
min concentration has been added. The usual toxico-
logical tests, hormone and various function tests are
described. This is an indispensible book for the hospital
or physician’s laboratory.

* * *

TECHNIQUES OF CONCEPTION CONTROL. By Robert
Latov Dickinson, M.D., Former President, American Gyne-
cological Society; and Woodbridge Edwards Morris, M.D.,
General Medical Director, Birth Control Federation of Ameri-
ca. A practical manual issued by the Birth Control Federation
of America, Inc. With fifty illustrations. Baltimore: The

Williams and Wilkins Company, 1941. Price: $.50.

This is a paper pamphlet in which is described, with
the utmost detail, the theory, principles, use, abuse,
and efficiency of the common types of appliances and
practices in use. Numerous diagrams and drawings
make the text very clear and helpful.

* * *

THE THERAPY OF NEUROSES AND PSYCHOSES. A
Socio-Psycho-Biologic Analysis and Resynthesis. By Samuel
Henry Kraines, M.D., Associate in Psychiatry, University of
Illinois, College of Medicine; Assistant State Alienist, State
of Illinois; Diplomate of American Board of Psychiatry and
Neurology. Philadelphia: Lea and Febiger, 1941. Price: $5.50.
The publisher states that “This work has been
written to aid the physician, who has not specialized in
psychiatry, in dealing with the psychoneurotic patients.
It covers the principles of treatment the practicality of
which is demonstrated * * Many invaluable sugges-
tions are given to the physician as to the conduct of
treatment for his psychoneurotic patient. It is interest-
ingly and practically written. The arrangement of chap-
ter headings is especially designed for the general prac-
titioner who seeks assistance rather than for the psy-
chiatrist. It is recommended to every general practi-
tioner.

* * *

MODERN DRUGS IN GENERAL PRACTICE. By Ethel
Browning, M.D., Ch.B. A William Wood Book. Baltimore:
The Williams & Wilkins Company, 1940. Price: $3.00.
This is by an English author and was printed in
England. The book presents some viewpoints on the
action of drugs which are not commonly accepted in
this country and there are also some drugs discussed
which should be given more general use in the United
States. For the therapeutist this book should offer
numerous valuable suggestions and certainly additional
information.

In Lansing

HOTEL OLDS

Fireproof

400 ROOMS

READING NOTICES

LEDERLE ADDS CEREVIM TO LIST OF
COUNCIL ACCEPTED PRODUCTS

Most recent addition to the Lederle line of ethical
pharmaceuticals and biologicals is Cerevim, an advanced
cereal formula for babies and infants, formerly dis-
tributed by the Cerevim Products Corporation.

In announcing the addition of this established prod-
uct to their line, Lederle Laboratories emphasize that
they will continue to follow their own policy of detail-
ing physicians and selling through retail druggists only
— which is the same basis on which substantial sales
for Cerevim have been established already.

Cerevim is Council-Accepted and has the full en-
dorsement of the Council on Foods of the American
Medical Association. Cerevim is a mixture of natural
foods scientifically blended, and provides an excellent
natural source of Vitamin B Complex factors and
Iron. The Calcium and Phosphorous are derived pri-
marily from milk. The formula was developed on the
basis of five years’ research at leading Eastern Uni-
versities and clinics which preceded the product’s intro-
duction in 1937.

Lederle Laboratories have outlined sales efforts which
will include emphasis on Cerevim not only for infant
feeding, but for other uses in the medical field in which
soft, bland diets are indicated.

A SUPER MICROSCOPE

Two years before the Lilly plant was founded, Ed-
ward Bausch completed the manufacture of the first mi-
croscope in the western hemisphere. It soon became an
essential piece of laboratory apparatus for study and
research in the pharmaceutical industry. But many
living and non-living things remained that could not be
seen — micro-organisms that cause diseases like measles,
mumps, and poliomyelitis ; and the structure of particles
of matter of especial interest to physicists, chemists,
and kindred scientists.

The reason that the optical microscope cannot reveal
these smaller objects has been due to limitations of
light itself. Further advances have now been made and
electrons have come to man’s aid in the extension of his
vision. This wave length is but a minute fraction of a
light wave, and with the electron microscope direct
magnifications of 10,000 to 30,000 are attained, and
photographic enlargements to 100,000 and even 200,000
times are possible.

The Lilly Research Laboratories are among the first
to procure one of these new instruments. Undoubted!}’
the extension of vision made possible will result in
truly great advances in science and perhaps the further
conquest of disease.

THE MAPLES

A Private Sanitarium for the Treatment of Alcoholism

R.F.D. 3, LIMA, OHIO
• Phone: High 6447

Located 2^ Miles East of Corner on
U. S. 30 N.

Registered by the A.M.A.

F. P. Dirlam A. H. Nihizer, M.D.

Superintendent Medical Director

406 Jour. M.S.M.S.

Say you saw it in the Journal of the Michigan State Medical Society

EBfZYMOL

A Physiological Surgical Solvent

Prepared Directly From the Fresh Gastric Mucous Membrane

ENZYMOL proves of special service in the treatment of pus coses.

ENZYMOL resolves necrotic tissue, exerts a reparative action, dissipates foul odors;
a physiological, enzymic surface action. It does not invade healthy tissue; does not
damage the skin. It is made ready for use, simply by the addition of water.

These are some notes of clinical application during many years:

Abscess cavities
Antrum operation
Sinus coses
Comeal ulcer

Carbuncle
Rectal fistula
Diabetic gangrene
After removal of tonsils

After tooth extraction
Cleansing mastoid
Middle ear
Cervidtis

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Please send me lull information on the Burdick RC-2 Dual Timing Rhythmic Constrictor.

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Address

City State

June, 1941

Say you saw it in the Journal of the Michigan State Medical Society

415

NQCfflGAN MEDICAL SERVICE

Michigan Medical Service is issuing a new
Identification Card which will permit a more
ready determination of whether the subscriber
is enrolled in the Surgical Benefit Plan or the
Medical Service Plan. The new Cards carry
the statement “This Card must be shown to
your doctor when you request services.” A
similar statement is in the subscriber’s certifi-
cate and is also emphasized at the time of
presentation. Subscribers should, therefore,
present their Identification Cards when they
request services. However, it would be help-
ful if the doctor or the doctor’s secretary would
ask the patient whether or not he is a sub-
scriber to Michigan Medical Service.

Payments for April

The Executive Committee of Michigan
Medical Service reports that during the first
months of this year the expected seasonal in-
crease in services was considerably emphasized
by somewhat of an epidemic of influenza and
measles. In addition, there has been a sub-
stantial increase in enrollment during the past
six months, with the usual resultant demand
for services during the first months that the
certificate is in force.

In view of this situation and in the interests
of conservative management, the Executive
Committee has authorized payment for serv-
ices rendered during the month of April on a
basis somewhat lower than that applied during
the past thirteen months.

An analysis of Monthly Service Reports in-
dicates quite clearly that approximately 40 per
cent of the services rendered would not have
been obtained if the subscriber had to pay the
doctor directly. This means more patients for
the doctors and more adequate medical service
for the subscribers.

Reporting

The last Bulletin explained that the Execu-
tive Committee felt that Monthly Service Re-
ports should not be authorized for payment if
received 90 days or more after the service has
been rendered. It is requested that all reports
for services to subscribers be mailed promptly.

MICfflGAN MEDICAL SERVICE REGISTRATION
HONOR ROLL

(As of May 10, 1941)

100 Per Cent

Barry

Dickinson-Iron

Mason

90 to 99 Per Cent

Calhoun

Ingham

Manistee

Mecosta-Osceola-Lake

Menominee

Monroe

Newaygo

Tuscola

St. Joseph

80 to 89 Per cent

Allegan

Bay-Arenac-Iosco

Chippewa-Mackinac

Clinton

Delta-Schoolcraft

Eaton

Gogebic

Gratiot-Isabella-Clare

Hillsdale

Kalamazoo

Kent

Lenawee

Medical Society of North Central Counties

Midland

Muskegon

Oceana

Ontonagon

Ottawa

Saginaw

75 to 79 Per Cent

Branch

Grand Traverse-Leelanau-Benzie

Houghton-Baraga-Keweenaw

Lapeer

Northern Michigan
Oakland

Wexford-Missaukee

Registration of Physicians

There has been a very encouraging increase
in the registration of physicians. More than 3,-
485 doctors of medicine — approximately 80 per
cent of the total possible number — are partici-
pating and are ready to render services for sub-
scribers. This splendid cooperation, which has
made possible the operation of the prepayment
medical service plan, has gained nation-wide
recognition for Michigan doctors.

416

Jour. M.S.M.S.

on thee little man...

The blessings of sunlight and simple, quiet existence
are often beyond the realization of today’s children.
Numerous cases of borderline deficiencies are being
constantly observed by the profession.

Studies* in groups of all ages have shown that
CocoMALT added to the diet results in substantial
gains. The vitamin-mineral character of Cocomalt
supplies important nutrients in diets of young and
old . . . vital elements that must be present in optimal
amounts to insure vibrant health. Cocomalt is a
delicious beverage that acts as an incentive to drink
more milk.

Cocomalt

a : A -D r?.

contains calcium, phosphorus, iron, vita-
mins A, Bi, D, G . . . Quick energy and body building nutrients.

Say \ou saw it in the Journal of the Michigan State Medical Society

June, 1941

SliM^^DEllcioUS ■

bBWblEiONIC lioit AlljAGiS

PAVIStCOMPANYr HOBOKEN, N. J.

* Archives of Pediatrics — 56:Nov., 1939
Medical Record — Aug. 21, 1940

Xr HALF A CENTURY AGO X-

Annual Address on Practice of Medicine

PHTHISIS*

HENEAGE GIBBES. M.D.

Ann Arbor, Michigan

Pulmonary consumption has existed among men as
far back as we have any historical record of disease.
It is credited by Hirsch with about two-sevenths of all
deaths, and lately has excited so much interest in the
profession that I need offer no apology for making
it the subject of my address.

I use the term “pulmonary consumption” to include
those cases where progressive wasting of the body is
associated with consolidation and the formation of
cavities in the lungs.

In the earliest account of this disease we find it
described as a suppuration of the lungs. Later on,
we find an account of large and small tubercles asso-
ciated with suppuration and ulceration.

The word tubercle was first used to denote any small
swelling or node, and as far back as 1700 we find
Mangetus comparing the tubercles found in the lungs,
liver, and spleen with millet seeds.

We find various descriptions of this disease after this,
and controversies arising as to whether all consolida-
tions in the lungs were formed of tubercles. Two
forms of tubercle were spoken of, the miliary and
tuberculous infiltration, and we come to the time of
Niemeyer, who considered that a large majority of
cases of phthisis were inflammatory. This view was
widely held until a comparatively recent period and
is still supported by high authorities.

At the beginning of the year 1882, the majority of
clinicians of any standing firmly believed in the duality
of phthisis.

In April of that year came the announcement that
Dr. Robert Koch had discovered the bacillus of tuber-
culosis, and that inoculation with this organism invari-
ably reproduced the disease in susceptible animals.
Everyone at once set to work examining sputum and
recording the results of their observations. Watson
Che3me was sent by the Association for the Advance-
ment of Scientific Research to Berlin to examine Koch’s
work, and, if possible, corroborate it. This he did by
going to Koch’s laboratory, obtaining material from him
and working by his methods, and getting results which
he published in the “Practitioner” for April, 1883, and
in which article he demonstrated by illustrations and
descriptions that he did not know the difference be-
tween a parasitic worm and . a striped muscle fibre.
And this man’s work is held, in the last editions of
the English textbooks on pathology, to be the cor-
roboration of Dr. Koch’s results.

The accepted position at the present time with a
large majority of practitioners in this country is, that
wherever the bacillus tuberculosis is found there is
tuberculosis, and it is this position which I propose to
discuss in this address.

We are told that the tubercle bacillus is the virus
of tuberculosis, and we, therefore, ought to be fully
aware of the conditions under which it exists in dis-
ease, so that we may have some rational idea as to
the treatment we should adopt in these cases.

Now comes the question, if we are going to investi-

•Presented at the Twenty-sixth Annual Meeting of the
Michigan State Medical Society, at Saginaw in June 1891.

420

gate this disease, what morbid conditions shall we take
as the basis on which to commence? Naturally, we
should say, those in which cavities exist in the lungs,
but we find that tubercle bacilli are found in cases
where there are no cavities; we must, therefore, extend
our basis and take in consolidations. Now we find
these existing in a number of different conditions —
in the old fashioned pulmonary phthisis, in chronic
tuberculosis, in acute miliary tuberculosis, in acute
pneumonia, in the lesions of syphilis and in hydatid
disease, also in cancer and sarcoma. All these cause
consolidation; but to simplify matters we will leave
out all but pulmonary phthisis, chronic tuberculosis and
acute miliary tuberculosis. These three diseases are
characterized by the formation of consolidations in the
lungs, and in all of them tubercle bacilli are found.
Therefore, with the prevailing view, these are all
tuberculosis, and are all caused by the action of the
tubercle bacillus of Koch.

To commence with pulmonary phthisis; as I under-
stand it, this is a common result in a case of catarrhal
or broncho-pneumonia either in a weakly patient or
where the disease is of unusual severity, and is brought
about most commonly in one of two ways. We will
take for an example a delicate girl getting her feet
wet and catching a cold; this passes into bronchitis
and the inflammatory process extending, involves the
small bronchioles ; the case then becomes one of capil-
lary bronchitis. When this stage is arrived at, two
courses may be taken by the disease : the inflammation
may pass on from the bronchioles into the lung sub-
stance and develop into a case of catarrhal or broncho-
pneumonia, or the products of inflammation may block
up one or more of the small bronchioles by forming
a plug in them, which is drawn further in and more
firmly fixed at each inspiratory effort, the result being
that no more air can enter those lobules of the lung
supplied by the plugged bronchioles. When this has
taken place, the air imprisoned in these lobules soon
becomes absorbed and they pass into a state of col-
lapse. Now in any form of collapse of the lung the
greatest danger arises from the almost inevitable in-
flammatory action, which is at once set up in the air
vesicles in this collapsed condition.

We have then, in these cases,, a position of the
lung consolidated, either by direct extension of the
inflammatory action from the bronchioles, or by inflam-
matory action set up by the collapsed condition, which
is directly brought about by the inflammation in the
bronchioles. Now, supposing that this delicate girl has
not sufficient vitality to throw off this inflammatory,
process in her lungs, but that it is allowed to go on
until the acuteness of the inflammation has destroyed
the affected part and it has become devitalized.

We have then one or more portions of the lung in
a necrosed condition ; this dead tissue undergoes a
further disintegration and becomes softened and
caseated, and this softened mass is expectorated through ^
the bronchiole connected with it, leaving behind a ^
cavity. This is an inflammatory process from the begin-
ning to the end, and we are all aware how often the

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Say you saw it in the Journal of the Michigan State Medical Society

421

HALF A CENTURY AGO

1

whole of this process takes place with great rapidity,
and the wet feet result in the death of the patient.
I do not think there is anything stra ned in this ex-
ample, but that something of the kind must be familiar
to you all. We will now inquire into the part played
by the tubercle bacilli in this case, for it is in these
cases that we find them in enormous numbers, large,
long, and full of the so-called spores. We find the
sputum loaded with them as soon as the consolidation
begins to break down, and we find them in the bronchi-
oles of cases of capillary bronchitis, dying in that
condition. Now, where do they come in, in these cases:
as the virus or causation of the disease? We will now
take chronic pulmonary tuberculosis ; this is a condi-
tion with a totally different history. We have here
a disease of insidious origin, with gradually iuncreasing
weakness, anemia, nocturnal cough and irregular fever,
and physical signs, at first very obscure, at one apex,
gradually increasing until marked consolidation is
found, which then breaks down and ends in the forma-
tion of a cavity. In the meantime, the disease is
steadily progressing in this lung and a similar change
is set up in the apex of the other organ. In the early
stage, before there is any destruction of lung tissue,
we do not get ‘tubercle bacilli in the sputum, but when
the formation of a cavity begins we then find them.
Their number varies, however, enormously, and in some
few cases they are never found in the sputum during
life, or in the lungs after death, although these are
full of cavities.

Tuberculosis is a much more formidable disease.
It commences insidiously and is often far advanced
before its presence can be detected. Consisting, as
it does, of a new growth of fibroid tissue derived
from the connective tissue of the lungs, it is evident
that a good deal of this new tissue may be formed
before it can be detected by physical examination. It
generally commences in the apex of the lungs and
grows downwards. It has this peculiarity, that after
growing to a certain size, which varies according to
the chronicity of the process, the center undergoes
a. necrotic change and loses its vitality. Although one
of these tubercular masses looks large to the naked
eye and appears to be homogeneous, it is in reality
made up of an aggregation of tubercles, and this tuber-
cular process is always progressing on the outside,
while the center is breaking down. Little tubercles
in the earliest stage can be found in the periphery.
These tubercles can grow rapidly, as is shown in acute
miliary tuberculosis, where the lungs are found filled
from apex to base with them, in all stages, but of
small dimensions, also in tubercle of the choroid, where
the growth is the same. Whatever the cause may be of
this condition, it is something which must be carried
throughout the lungs by the circulation in acute miliary
tuberculosis, but which must have some other distribu-
tion in those more chronic forms where the apex is
the first part affected. Dr. Shurly and I have now
been working together on this subject for three years,
and we have gone most carefully into all the condi-
tions found. Our investigations have resulted in the
differentiation I have just stated, and also in causing
us to consider the tubercle bacillus more as an acces-
sory than an actual factor in the production of tuber-
culosis. My own view, that there was some morbid
product responsible for the irritation resulting in tlie
new growth tubercle, was formed before I came to
this country, and on my arrival here I was glad to
find Dr. Shurly, from work he had been doing in
this direction, was also of the same opinion. We pro-
cured monkeys and carefully studied the disease pro-
cesses in them, and having satisfied ourselves that we
had a morbid chemical substance to deal with, we set
to work to try to neutralize it. After numberless trials.

we found that we could do this with iodoform, but
that substance set up a fatty change in the liver and
had to be discarded. We afterwards found that iodine
would prevent the formation of tubercle in inoculated
animals, and that chloride of gold and sodium would
render tubercle bacilli innocuous, without, however,
killing them. This seemed to be the result we were
aiming at, as we always considered that the so-called
pure cultures of tubercle bacilli, were not really pure,
but as in the case of the Jequirity bacillus, contained
some morbid product introduced from the original
source. We made a large number of experiments on
animals by inoculating them with tubercular material,
leaving them for a week, and then putting them under
treatment. We used in the first place monkeys, but
they were too expensive, as we required large num-
bers. Guinea pigs were fortunately found to give ex-
actly the same reaction, and they were afterwards used
for all the ordinary experiments. We found that put-
ting them under our treatment, a week after they had
been inoculated with tubercular material, confined the
lesion to the sore at the seat of the inoculation. We
then tried putting healthy animals under our treatment
for a week, and in some cases a fortnight, before in-
oculating them with tubercular mater’al, and in these
cases we prevented even the formation of an abscess
at the seat of the inoculation.

We now considered that we were in a position to
try our remedy on human patients, which we did with
the most gratifying results. This investigation has been
most thorough, and the results we have obtained were
from a study of the disease in all its varying condi-
tions. All animals have been most carefully examined
during life and after death, and the results recorded,
and when I state that over three hundred guinea pigs
and nearly one hundred monkeys have been used, be-
sides a number of other animals, I think you will ad-
mit that we have not arrived at any hasty conclusions.

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Tour. M.S.M.S.

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Say you sazc it in the Journal of the Michigan State Medical Society

423

CREDIT IS DUE

The following physicians registered at the 1940 De-
troit convention on Tuesday and Wednesday, Septem-
ber 24 and 25, 1940:

Tuesday

W. H. Alexander, Iron Mountain; A. D. Allen, Bay City;
Norman M. Allen, Detroit; Emil Amberg, Detroit; N. H. Amos,
Battle Creek; E. B. Andersen, Iron Mountain; A. L. Arnold,
Jr., Owosso.

Carl E. Badgley, Ann Arbor; Robert H. Baker, Pontiac;
Wm. Ballard, Bay City; Chas. W. Balser, Detroit; W. H. B.
Barnum, Fremont; W. E. Barstow, St. Louis; S. G. Bates, De-
troit; T. I. Bauer, Lansing; Otto Beck, Birmingham; M. G.
Becker, Edmore; C. D. Benson, Detroit; G. W. Benson, Escan-
aba; H. M. Best, Lapeer; H. G. Bevington, Detroit; Andrew P.
Biddle, Detroit; Wm. G. Birch, Sault Ste Marie; Wm. L. Bird,
Greenville; Wm. E. Blodgett, Detroit; D. C. Bloemendaal,
Zeeland; Chas. T. Bower, Detroit; C. E. Boys, Kalamazoo;

D. R. Brasie, Flint; R. S. Breakey, Lansing; A. L. Brooks, De-
troit; James D. Bruce, Ann Arbor; C. F. Brunk, Detroit; A.
S. Brunk, Detroit; J. H. Burley, Port Huron; V. N. Butler,
Detroit.

J. E. Caldwell, Detroit; A. L. Callery, Port Huron; A. M.
Campbell, Grand Rapids; Don M. Campbell, Detroit; Joseph
Carp, Detroit; C. H. Carpenter, Detroit; E. I. Carr, Lansing;
H. R. Carstens, Detroit; Wm. J. Cassidy, Detroit; Chas. Cas-
trap. Dearborn; A. E. Catherwood, Detroit; A. W. Chase,
Adrian; Wm. P. Chester, Detroit; Lloyd H. Childs, Flint; C.
A. Christensen, Dearborn ; L. G. Christian, Lansing ; Harold

E. Clark, Detroit; T. Percy Clifford, Detroit; H. S. Collisi,
Grand Rapids; R. C. Connelly, Detroit; Henry Cook, Flint;
W. B. Cooksey, Detroit; R. G. Colyer, Detroit; G. A. Conrad,
Marquette; T. H. Cooper, Port Huron; Burton R. Corbus,
Grand Rapids; Henry F. Crossen, Detroit; Ethan B. Cudney,
Pontiac; Howard H. Cummings, Ann Arbor; George J. Curry,
Flint; Frank E. Curtis, Detroit.

Ernest D’Alcon, Detroit; Luther W. Day, Jonesville; T. E.
DeGurse, Marine City; Dean C. Denman, Monroe; C. F. De-
Vries, Lansing; A. S. DeWitt. Detroit: Stuart L. DeWitt,
Grand Haven; Harry F. Dibble, Detroit; M. P. Dillard, Detroit;
Wm. M. Donald, Detroit; Sam W. Donaldson, Ann Arbor; J.
D, Donovan, Detroit; Harvey E. Dowling, Detroit; F. M.
Doyle, Kalamazoo; F. Drummond, Kawkawlin; O. E. Dutchess,
Detroit.

C. H. Eisman, Detroit; C. T. Ekelund, Pontiac; W. C. Ellet,*
Benton Harbor; H. B. Elliott, Flint; Paul H. Engle, Oliver;
Joseph M. Erman, Detroit.

David H. Fauman, Detroit; Geo. E. Fay, Detroit; H. B.
Fenech, Detroit: W. L. Finton, Jackson: E. W. Fitzgerald,
Detroit; Edw. O. Foss, Muskegon; L. Fernald Foster, Bay
City; Mable Freeman, Detroit.

C. B. Gardnei^ Lansing; H. H. Gay, Midland; L. O. Geib,
Detroit; ,,J. S. Gellert, Detroit; L. W. Gerstner, Kalamazoo;
Wm. H. Gordon, Detroit; C. S. Gorsline, Battle Creek; S. E.
Gould, Eloise; T. K. Gruber, Eloise.

A. T. Hafford, Albion; H. C. Hansen, Battle Creek; F. E.
Hassen, Detroit; R. B. Harkness, Hastings; S. W. Hartwell,
Muskegon; C K. Hasley, Detroit; Wilfrid Haughey, Battle
Creek; J. E. Hauser, Detroit; T. F. Heavenrich, Port Huron;
L. L. Henderson, Detroit; Thos. J. Henry, Detroit; L. Chas.
Hess, B*ay City; Lee Hileman, Ecorse; Louis J. Hirschman,
Detroit ; T. E. Hoffman, Detroit ; Martin H. Hoffmann, Eloise ;
Roy Herbert Holmes, Muskegon; R. J. Hubbell, Kalamazoo;
J. G. Huizinga, Holland; L. W. Hull, Detroit; W. H. Huron,
Iron Mountain.

Stanley W. Insley, Detroit; Arthur Isaacson, Detroit.

R. C. Jamieson, Detroit; Alpheus Jennings, Detroit; L. J.
Johnson, Ann Arbor; Euclide Joinville, Detroit; J. Jonikaitis,
Detroit.

H. I. Kallet, Detroit; Joseph A. Kasper, Detroit; L. R. Kea-
gle. Battle Creek; Frank Kelly, Detroit; Chas. S. Kennedy,
Detroit; Wm. Y. Kennedy, Detroit; C. R. Keyport, Grayling;
Paul C. Kingsley, Battle Creek; F. O. Kirker, Sandusky; J.
G. Kirker, Detroit; G. R. W. Kirton, Calumet; Paul A. Klebba,
Detroit; S. Kleinman, Detroit; V. F. Kling, Ionia; Paul W.
Kniskern, Grand Rapids; Harold J. Kullman, Detroit.

N. F. LaFrance, Battle Creek; Geo. L. LeFevre, Muskegon;
W. E. Larson, Levering; P. L. Ledwidge, Detroit; W. C. Lam-
bert, Marquette; John S. Lambie, Pontiac; M. B. Landers, Jr.,
Detroit; Lawrence LaPorte, Gladwin; V. S. Laurin, Muskegon;
Chas. E. Long, Grand Haven; Martha Longstreet, Saginaw;
Sherman L. Loupee, Dowagiac; Henry A. Luce, Detroit; Earl

F. Lutz, Detroit.

Archibald McAlpine, Detroit; G. L. McClellan. Detroit; Roy

D. McClure, Detroit; Carey P. McCord, Detroit; F. T. Mc-
Cormick, Detroit; J. Earl McIntyre, Lansing; Richard M. Mc-
Kean, Detroit.

. Robert B. Macduff, Flint; T. Marwil, Detroit; Elta MaSon,
Flint; J. D. Matthews, Detroit; Stuart F. Meek, Detroit; Hel-
muth Meinecke, Detroit; C. M. Mercer, Battle Creek; Earl G.

424

Merritt, Detroit; A. H. Miller, Gladstone; Harold A. Miller,
Lansing; J. Duane Miller, Grand Rapids; Norman F. Miller,
Ann Arbor; Frederick B. Miner, Flint; Carl A. Mitchell, Ben-
ton Harbor; B. T. Montgomery, Sault Ste Mane; V. M.
Moore, Grand Rapids ; Harold Morris, Detroit ; K. M. Morris,
Saginaw; Ray S. Morrish, Flint; B. W. Morse, Whitehall; F.
J. Murphy, Detroit; Dean W. Myers, Ann Arbor.

W. E. Nesbitt, Alpena; I. D. Nickerson, Detroit.

C. W. Oakes, Harbor Beach; E. A. Oakes, Manistee; D. J.
O’Brien, Lapeer; R. E. Olsen, Pontiac; J. J. O’Meara, Jack-
son; G. O’Sullivan, Mason.

Geo. H. Palmerlee, Detroit; G. C. Penberthy, Detroit; Roy C.
Perkins, Bay City; H. E. Perry, Newberry; R. H. Pino, De-
troit; H. W. Plaggemeyer, Detroit; F. A. Poole, Saginaw; H.
W. Porter, Jackson; J. J. Predergast. Detroit; D. W. Patter-
son, Port Huron.

H. E. Randall, Flint; A. P. Rawson, Addison; F. E, Reeder,
Flint; Wm. S. Reveno, Detroit; C. F. Rice, Jr., Detroit; Philip
A. Riley, Jackson; J. M. Robb, Detroit; E. R. Robbins, Detroit.

E. O. Sage, Dearborn; G. B. Saltonstall, Charlevoix; H. F.
Sawyer, Detroit; J. B. Seeley, Dearborn; A. H. Siebert, East
Detroit; H. T. Sethney, Menominee; A. D. Sharp, Albion;
Milton Shaw, Lansing; S. A. Sheldon, Saginaw; Geo. A, Sher-
man, Pontiac; D. L. Sherwood, Detroit; C. E. Simpson, De-
troit; E. F. Sladek, Traverse City; R. M. Slate, Detroit; A. B.
Smith, Grand Rapids; C. V. Smith, Detroit j Carl F. Snapp,
Grand Rapids; G. H. South wick. Grand Rapids; E. D. Spald-
ing, Detroit; P. C. Spencer, Lansing; R. A. Springer, Center-
ville; Wm. J. Stapleton, Detroit; H. B. Steinbach, Detroit;
D. C. Stephens, Howell; A. E. Stickley, Coopersville ; H. D.
Strieker, Detroit; W. F. Strong, Ontonagon; C. K. Stroup,
Flint; O. D. Stryker, Fremont; O. H. Stuck, Otsego; P. E.
Sutton, Royal Oak; M. R. Sutton, Flint; Geo. F. Swanson,
Newberry.

Chas. A. Teifer, Muskegon; E. Terwilliger, South Haven;
Geo. Thosteson, Detroit; Clarence E. Toshach, Detroit.

C. E. Umphrey, Detroit; P. R. Urmston, Bay City.

C. K. Valade, Detroit; C. F. Vale, Detroit; V. H. Vande-
venner, Ishpeming; A. E. Van Nest, Detroit.

R. L. Wade, Coldwater; R. V. Walker, Detroit; J. S. Wen-
del, Detroit; A. V. Wenger, Grand Rapids; J. A. Wessinger,
Ann Arbor; Bernard Weston, Detroit; A. H. Whittaker, De-
troit; Anna L. Wilcox, Owosso; D. Bruce Wiley, Utica; H. W.
Wiley, Lansing; W. S. Williams, Flint; E. R. Witwer, De-
troit; R. A. C. Wollenberg, Detroit; M. G. Wood, Hart; Wm.
P. Woodworth, Detroit.

G. H. Yeo, Big Rapids.

Wednesday

Charles D. Aaron, Detroit; James R. Acocks, Houghton; Ches-
ter H. Adams, Grand Blanc; Leopold Adler, Detroit; Sidney
Adler, Detroit; E. J. Agnelly, Detroit; H. R. Allen, Battle
Creek; R. W. Alles, Detroit; Herbert S. Allison, Grosse Pt. ;
C. L. Ames, Detroit; Florence Ames, Monroe; T. G. Amos, De-
troit; Walter Anderson, Detroit; Raymond C. Andries, Detroit;

F. T. Andrews, Bay City; J. W. Ankley, Detroit; R. E. Anslow,
Detroit; George L. Anthony, Flint; Philips R. Appel, Detroit;
Burke Arehart, Detroit; A. G. Armstrong, Detroit; Z. R. Aschen-
brenner, Farmington; J. Norris Asline, Essexville; A. U. Axel-
son, Detroit.

Myron Babcock, Detroit; M. E. Bachman, Detroit; A. C.
Bachus, Powers; Vinton A. Bacon, Detroit; Harry E. Bagley,
Dearborn; Robert Bailey, Clair Shores; Abel J. Baker, Grand
Rapids; Charles H. Baker, Bay City; Clarence Baker, Detroit;
Joseph A. Bakst, Detroit; M. A. Balerski, Detroit; F. W. Bald,
Flint; Robert S. Ballmer, Midland; Gordon W. Balyeat, Grand
Rapids ; F. C. Bandy, Sault Ste Marie ; Marion F. Barker, De-
troit; Howard B. Barker, Pontiac; Louis L. Barnett, Detroit; F.
Elizabeth Barrett, Kalamazoo; S. E. Barnett, Detroit; F. W.
Bartholic, Grass Lake; Walter M. Bartlett, Benton Harbor; J.
R. Barton, Detroit, A. Robert Bauer, Detroit ; Ernest W. Bauer,
Royal Oak; W. L. Baumann Detroit; John G. Bayles, Detroit;
Willard Beattie, Ferndale; M. B. Beckett, Allegan; Carl B. Bee-
man, Grand Rapids; L. E. Beeuwkes, Dearborn; S. K. Beigler,
Detroit; Henri Belanger, River Rouge; A. L. Benedict, Jr.,
Muskegon; C. H. Benning, Royal Oak; Davis A. Benson, De-
troit; Neil Bentley, Detroit; Louis BeresL Detroit; Lawrence
A. Berg, Centerville ; Richard H. Berg, Oxford ; Clarence A.
Berge, Detroit; Harry S. Berman, Detroit; Robert Berman, De-
troit; Bernard Bernbaum, Detroit; Samuel Bernstein, Detroit;
Eli N. Bernstein, Flint; Wm. L. Bettison, Grand Rapids; E. A.
Bicknell, Detroit; F. R. Bicknell, Detroit; Don L. Bishop,
Flint; N. M. Bittrich, Detroit; Perry S. Black, Detroit: M. J.
Blaess, Detroit; A. C. Blakeley. Flint; E. W. Blanchard, Decker-
ville; F. N. Blanchard, Detroit; Jos. Bleier, Detroit; Abraham
BlocK D‘=troi* : N. Berneta Block. l ansing: Franz Blumenthal,
Detroit; Jas. J. Boccia, Detroit; A. P. Boell, Detroit; Leon M.
Bogart, Flint ; S. Stephen Bohn, Detroit ; A. T. Bonathan, Flint.

The above list represents the registration for Tues-
day, September 24, and part of Wednesday, September
25, 1940. The list of those who registered subsequently
will be published in succeeding issues of The Journal.

Tour. M.S.M.S.

TKe JOURNAL

of the Michigan State Medical Society

Issued Monthly Under the Direction of the Council

Volume 40

June, 1941

Number 6

Gonncoccal Infections

Diagnosis and Criterion of Cure*

By Adolph Jacoby, M.D.

Medical Supervisor Social Hygiene Clinics
New York City Dept, of Health
Diagnosis in Women

Adolph Jacoby, M.D.

M.D., Cornell Medical School, 1909. As-
sistant Professor of Gynecology, New York
Post Graduate Hospital. Lecturer, Preventive
Medicine, New York University College of
Medicine. Medical Supervisor, City of New
York Department of Health. Special Con-
sultant, United States Public Health Service.

Clinic Consultant, New York State Depart-
ment of Health. Member, American Medical
Association and American Neisserian Medi-
cal Society. Fellow, Academy of Medicine,

Section of Obstetrics and Gynecology; and
American College of Surgeons.

■ The diagnosis of gonorrhea in women is
very frequently overlooked both in private
practice and in institutions. This may be readily
appreciated when it is noted that of the 12,928
cases of gonorrhea reported in 1938 in New
York City, 3,121 were females, and in 1939, of
12,807 cases, 2,827 cases were females (Table
I). This indicates that male gonorrhea is reported
about three times as much as is female.

That this condition is not a local occurrence

TABLE I. incidence OF GONORRHEA
reported to new YORK CITY

Male

Female

Total

1931-1936

54,419

14,011

68,430

1938

9,807

3,121

12,928

1939

9,980

2,827

12,807

Total

74,206

19,959

94,165

•Presented before Ingham County Medical Society as part of
the Fall Symposium on Gonorrhea, 1940.

may be gathered from statistics for the years
1935 and 1936 of England and Wales. During
1935, 27,506 males and 7,732 females having
gonorrhea were reported; during 1936, 28,137
males and 7,715 females were reported (Table
II).

TABLE II. INCIDENCE OF GONORRHEA REPORTED
TO ENGLAND AND WALES

Male

Female

Total

1935

27,506

7,732

35,238

1936

28,137

7,715

35,852

Total

55,643

15,447

71,090

N.Y.C.

74,206

19,959

94,165

Grand Total

129,849

35,406

165,255

The reason for the marked difference in
numbers of cases of females reported lies large-
ly in the fixed belief of most physicians that
the diagnosis can only be made on laboratory
evidence. The usual laboratory evidence em-
ployed is the smear, culture, and complement
fixation blood test. The value of each of these
laboratory procedures in detecting gonorrhea
will be briefly discussed.

Smear. — In order to derive the utmost in-
formation from smear examination, it is essential
that the smears be carefully taken. The secretion
from each source should be obtained on a swab
with as little contamination from adjacent areas
as possible. The smear, itself, should be care-
fully rolled out on the slide and examined
after being stained by Gram stain. The interpre-
tation of the smear must be carefully done. In
an analysis of 1,482 women examined in prison
and found to have gonorrhea, 34.2 per cent

June, 1941

435

GONOCOCCAL INFECTIONS— JACOBY

TABLE III. COURT CASES WOMEN

January through September, 1940

Total Examinations

4,262

100.0%

Diagnosed Gonorrhea

1,482

34.8%

100.0%

Clinical Gonorrhea

528

12.4%

35.6%

— Positive Smear

57

1.3%

3.8%

— Positive Culture

124

2.9%

8.4%

— Positive Smear —
Culture

106

2.5%

7.2%

Positive Smear

115

2.7%

7.8%

Positive Culture

323

7.6%

21.8%

Positive Smear — Culture

229

5.4%

15.4%

had positive smears (Tables III and IV). If
the smear alone were used as a criterion for
diagnosis, 65.8 per cent of those diseased would
have been overlooked.

Culture. — Culture of the gonococcus requires
a well-organized and well-equipped laboratory
with bacteriologists specifically trained in gon-
ococcus culture diagnosis. There are, as yet, a
number of difficulties in the taking and trans-
mitting of specimens for culture diagnosis. A
time lapse beyond three hours after obtaining
the specimen is apt to show an overgrown cul-
ture. Among 1,482 cases diagnosed, 52.8 per
cent showed positive cultures (Tables III and
IV). If cultures alone were used as a diagnos-
tic criterion, 47.2 per cent of the cases would be
overlooked. It is, therefore, evident that both
smears and cultures are essential in reaching the
maximum number that can be diagnosed by lab-
oratory methods.

Complement Fixation Test. — The complement
fixation test in its present state is of very un-
certain value. In an investigation of the value
of the complement fixation test conducted in
1937,^ of a total of 760 patients examined, over
13 per cent showed non-specific reaction. This
one factor alone immediately indicates that the
test is not yet of sufficient value for diagnostic
or treatment control purposes.

Clinical Diagnosis

It is quite obvious that the most thorough
laboratory diagnosis falls far short of uncover-
ing the existing gonorrhea. This is readily seen

TABLE IV. FEMALE COURT EXAMINATIONS
First Nine ^lonths

Total Examinations

4,262

100.0%

Total Gonorrhea

1,482

34.8%

Clinical Gonorrhea

528

12.4%

Clinical Gonorrhea with Positive
Laboratory

287

6.7%

Laboratory Gonorrhea

667

15.7%

in our examination of 4,262 arrested prostitutes
where, out of this entire group, only 22.4 per
cent were discovered to have gonorrhea as a
result of smear and culture examination (Tables
III and IV). Admittedly, in this specialized
group, a considerably greater percentage are
actually infected with the disease. In order to
uncover as much of this balance as possible, it is '
essential that a thorough knowledge of clinical
diagnosis in gonorrhea be disseminated among
the medical profession. Unfortunately, at this :
time this knowledge is not very widely present, j
This is largely due to the fact that gonorrhea in j
women in the vast majority shows but very few j
clinical evidences of the existence of the disease, j
The clinical diagnosis of gonorrhea in women
depends upon a summation of the history, symp-
toms and clinical signs.

History. — In no other diagnosis is a detailed
and searching history so essential as in diag-
nosis of gonorrhea in women. This history
must include a searching inquiry into the past
existence of urinary symptoms and vaginal
discharge.

During the acute stage of the disease, fre-
quency and burning on urination are very prom-
inent symptoms. Also in this stage, there is in-
variably a profuse purulent cervical discharge
associated with general feeling of uneasiness in
the pelvis and general discomfort. Unfortunate-
ly. these acute symptoms do not last veiy^ long i
and in approximately seven to ten days, subsi- ■
dence of symptoms begins. Such a patient pre-
senting herself six to eight months later to the
doctor will, in all likelihood, have completely
forgotten these incidents. An essential part of
clinical diagnosis is inquiry into the occupation
and mode of life of the patient. All possible j
sex contacts with individuals who may harbor t

436

Jour. M.S.M.S.

GONOCOCCAL INFECTIONS— JACOBY

the infection must be uncovered. Most women
are more or less accustomed to the presence of
vaginal discharge and exacerbation of this dis-
charge for a brief interval is very likely to be
unreported six months later. It is, therefore,
necessary to jog the patient’s memory to uncover
such evidence.

Syniptoms. — The symptoms in the acute in-
fection are very clear and obvious. The patient
complains of marked frequency and burning on
urination, a profuse purulent vaginal discharge,
a feeling of discomfort and even pain in the
pelvis, occasionally accompanied by general symp-
toms of malaise and slight temperature. As a
rule, in uncomplicated infections such acute
symptoms subside in from seven to ten days.
The vast majority of patients present themselves
with an infection of anywhere from six months’
duration or longer. In such patients, unless
there is pelvic cellular or adnexal complications,
there is practically no discomfort but there is
slight frequency of urination and scant cervical
discharge. Where pelvic cellular or adnexal
complications exist, pain in one or the other
lower adbominal quadrants and back will be a
prominent symptom.

Clinical Signs. — The usual site of infection
involves both the cervix and the urethra. In
very few instances, probably less than 10 per
cent, does infection in one or the other location
alone exist. Infection may start, and usually
does, in the cervix inasmuch as the transmission
of the infection to the female usually occurs
from some male with a chronic disease. The
clinical signs in the acute stage of the disease
are clearly obvious. There is a marked redness
around the external urinary orifice associated
with edema and the presence of purulent dis-
charge exuding from the urethra or expressible
from the urethra with the slightest pressure.
The area of Bartholin’s gland, if the gland is
involved, will show a marked redness with per-
haps purulent secretion expressible from the
orifice of the duct. The cervix will show a
marked redness, edema and profuse purulent
discharge exuding from the external os. In
the chronic stage all these symptoms have di-
minished almost to the vanishing point and the
failure to detect the few remaining signs is fre-
quently responsible for the failure to diagnose
chronic gonorrhea. The area around the duct of

the Bartholin’s gland must be very carefully in-
spected. Occasionally the orifice of the duct is
surrounded by a small reddened areola, the m-
called Saenger’s spot. The duct, itself, may be
qnlarged, thickened or distended. The gland,
when enlarged, may be palpated by deep lateral
or posterolateral palpation with one finger in
the vagina and the other outside on the perineum.
Such enlargement may be inflammatory.

The urethra must be very carefully exam-
ined to detect the few physical signs remain-
ing in chronic urethral involvement. To un-
cover the slight discharge present, it is essen-
tial that the urethra be compressed at its vesi-
cal neck against the posterior surface of the
symphysis and the expression carried forward
from the vesical neck to the external urinary
meatus in a continuous maneuver. Great care
must be exercised not to release the pressure
especially after rounding the under border of
the symphysis and up the lower portion of
the anterior surface. This is important be-
cause otherwise Skene’s glands will not be ex-
pressed and very frequently the only existing
discharge remaining is located in these glands.

In addition to the presence of discharge, there
may be a thickening along the entire urethra
and in an old, chronic inflammation, the urethra
will roll under the finger like a lead pencil. The
ducts of Skene’s glands may be thickened and
feel like a strand of catgut in the tissues. The
cervix will always show more or less muco-
purulent or purulent discharge from the external
os. The cervical tissues will be bulky and edema-
tous, and, in approximately one-third of the
patients, cervical erosion and nabothian follicle
cysts will be in evidence. This picture in the
cervix is practically the same for inflammation
resulting from any other organism. The ex-
tension of inflammation from the cervix occurs
rapidly through the numerous lymphatics in the
parametrial tissues, particularly posteriorly and
laterally. This will give rise to inflammatory
thickening in the uterosacral and the bases of the
broad ligaments. Further extension through the
lymphatics in the broad ligaments will produce
tubal and ovarian involvements. Such involve-
ments are evidenced by thickening or mass for-
mation of varying size and tenderness in the
adnexa. Extension of the inflammation in the

June, 1941

437

GONOCOCCAL INFECTIONS— JACOBY

pelvic lymphatics may produce a pelvic cellular
involvement. In this event, the pelvic cellular
tissues above the vault of the vagina will be
extensively infiltrated, sometimes stony hard
and extremely sensitive to touch or motion of
any of the pelvic organs. An extension of this
inflammation beyond the confines of the cellular
tissues leads to a pelvic peritoneal involvement.

Summary

The diagnosis of gonorrhea must be made
from a summation of the various factors ob-
tained from the history, symptomatology, physi-
cal signs and laboratory reports.

The pertinent factors in the history are (1)
the possibility of contact with infected individ-
ual; (2) the past history of urinary frequency
and dysuria; (3) the past history of profuse
purulent vaginal discharge; (4) pain or dis-
comfort in the lower abdominal quadrant.

In the symptomatology, the important factors
are (1) the presence of frequency, especially
nocturia, and pain on urination; (2) the pres-
ence of vaginal discharge; (3) pain in the lower
abdominal quadrant may or may not be present.

The important physical signs are ( 1 ) purulent
discharge from the urethra; (2) purulent dis-
charge from Skene’s glands; (3) thickening
along the length of the urethra; (4) redness
around the orifice of Bartholin’s glands; (5)
redness or swelling in Bartholin’s glands; (6)
expression of pus from the orifice of Bartholin’s
glands; (7) purulent discharge from the external
cervical os; (8) hypertrophy and edema of the
cervix; (9) erosion of the cervix; (10) pres-
ence of nabothian follicle cysts; (11) thickening
and tenderness in the parametrial tissues espe-
cially posteriorly and laterally; (12) thickening
and tenderness in the adnexa; (13) pelvic cel-
lular inflammation; (14) pelvic peritoneal in-
flammation.

The factors of importance in the laboratory
reports are ( 1 ) positive gram negative intracellu-
lar or extracellular diplococci in the smear from
the secretions of the urethra, cervix or Bartholin’s
glands; (2) positive culture for gonococci from
the urethra, cervix or Bartholin’s glands.

It is by careful evaluation of all of the above
items that as much of gonorrhea in women as
it is possible to uncover with our present knowl-
edge will be diagnosed.

Criteria of Cure

In view of the present treatment of gonor-
rhea with various sulfonamide compounds and
the as yet unsolved problems in relation to
their action, it is especially important that our
criteria of cure be sufficiently searching to un-
cover any incompletely cured infection.

The Male.—Tho. first indication of cure is
the disappearance of all clinical signs of disease.
This includes an absence of urinary frequency,
dysuria and urethral discharge. Examination at
this time should show clear urine in both glasses
in the usual two-glass urine examination, nor-
mal prostate, seminal vesicles, Cowper’s glands,
and epididymes.

When this stage is reached, all treatment
should be suspended for one week. At the end
of that time, a urethral smear following strip-
ping or scraping of the mucosa is taken and
examined by Gram stain. If gonococci are ab-
sent, the prostate and seminal vesicles are mas-
saged and the secretion examined for gonococci
and pus cells. The practice of Pelouze (1939)^
of receiving this discharge in a tube of sterile
distilled water, centrifuging, and examining the
sediment is quite efficient.

If this examination is negative, provocative
measures are instituted. The first of these is the
passage of a urethral sound up to the posterior
urethra, and massaging the urethra over this
sound to express pus and gonococci from the
urethral crypts. The patient is given some
clean slides with instructions to secure any sub-
sequent discharge and bring it in for examina-
tion. After a four-day interval 1 to 2 c.c. of
0.5 to 1 per cent silver nitrate solution is in-
stilled through a cannula into the posterior ureth-
ra, continuing the injection as the cannula is
withdrawn. Examination of any resultant dis-
charge must be negative for gonococci. Prostate
should be massaged and secretion examined as
previously.

If all examinations are negative, the patient is
instructed to drink beer or other alcoholic bever-
age. Any resulting discharge must be examined
for gonococci. The above series of examinations
should be repeated twice after an intervening
monthly interval of negative clinical evidence of
disease.

If all examinations prove negative, the patient
may be pronounced cured but should be warned

Jour. M.S.M.S.

438

GONOCOCCAL INFECTIONS— JACOBY

that in all sexual intercourse for the suceeding six
months, he should resort to condom protection.
The time consumed in these tests is approximate-
ly five months.

Female Adult. — In the female, the determina-
tion of cure is more difficult than in the male.
Here, a searching examination to determine the
absence of all clinical and physical evidence of
infection is of the utmost importance. Xo deter-
mination of cure should be begun until all clinical
symptoms and physical signs are absent.

An examination of smears and cultures from
the urethra, Bartholin’s glands and cerv ix should
be made beginning one week after the cessation
of treatment. These specimens should be ob-
tained ever}’ week for the next six weeks and
eveiy other week thereafter until six more
smears and cultures have been taken and exam-
ined. All these specimens must be negative for
gonococci.

If, at the end of this period, all symptoms,
clinical signs, and laborator}* reports are nega-
tive, patient may be discharged as cured. Time
consumed is approximately five months.

Fenmle Children. — The cure of children with
vaginitis is only determinable after sufficient time
has elapsed following the cessation of treatment.
The first step in this determination is the absence
of all symptoms and clinical signs. At this point,
treatment is interrupted for one week. At the
end of this week, a series of six smears and
cultures from the vagina, cervix and rectum are
taken and examined at weekly intervals. Fol-
lowing this, a period of one month should elapse
before a repetition of another series of six
smears and cultures. At the end of this time,
still another series of six smears and cultures
should be taken and examined after a one
month’s lapse. The time consumed for these
series of examinations and observations is ap-
proximately six to seven months.

The necessity for such long observation is
indicated by the occurrence of what appears to
be spontaneous cure in this disease after an
interval of as much as twenty-four weeks after
the onset of the disease.

Conclusion

The control of gonorrhea depends largely
on the accuracy with which the existing dis-
ease, particularly in women, is uncovered

and the thoroughness with which cure is de-
termined after proper treatment has been car-
ried out. It is, therefore, necessary that in-
struction in accurate diagnosis be made avail-
able to the entire medical profession. It is
also necessary to indicate that the only sure
method for determining cure is by prolonged
observation and persistently negative physical
symptoms, physical signs, and smears and
cultures.

Provocative measures in the female have long
ago been abandoned. I feel that in the male also
provocatives are not of much value.

With the wide use of sulfonamide compoimds,
the only safe procedure for determining definite
cure is by reliance on prolonged observation and
persistently negative laboratory findings.

References

1. Jacoby, Adolph; Wishengrad, Michael, and Koopman, John:
An evaluation of the complement-fixation test for gonor-
rhea. Am. Jour. Svph., Conor, and Ven. Dis., 22:32,
1938.

2. Pelouze, P. S. : Gonorrhea in the Male and Female.

Third Edition, p. 223. Philadelphia: W. B. Saunders

Company.

LEADERSHIP

There can be no dictator in Organized Medicine. The
Board of Trustees is the Executive Body in both the
A.M.A. and in the State Societies. Increasingly, the
need for a similar executive group is being appreciated
and provided for in the component county societies.

The President is ahvajs a member of these Execu-
tive Groups, but even he has but one vote in the final
decision. The prestige of his office accords to him at
all times respectful attention, but it is the majority
opinion which prevails in the final decision.

The House of Delegates makes the final rules and
regulations. Even the Executive Board — the Trustees
— can make rulings to govern only until the next meet-
ing of the House of Delegates.

The members of the Board of Trustees accept the
responsibility inherent in their election, and serve un-
hesitatingly, fairly, and consistently in promoting the
best interests of the profession. — Th.e Journal of the
Medical Society of Xew Jersey, April, 1941.

“Immeasurable fertility” is a population slogan for
the German people coined bj’ Heinrich Himmler in a
new booklet for S.S. men. David M. Nichol, leviewing
the publication in a dispatch from Berlin to the New
York Post, saj's Himmler’s argument is that Germany
must have children to make up its losses on the battle-
fields if her victories are to be maintained. “To have
only two children is described as ‘co^\’ardly living.’
The standard must be four to six,” the booklet sa}'s,
and forecasts a Reich of 120 million persons, com-
pared to the present 90 million. “Illegitimate children,”
it goes on, “are also valuable members of the national
community, providing their parents are hereditary
healthy Nordics.” The dispatch points out that Himm-
ler’s appeal is another “attempt to stem a down\\^ard
trend in the birth rate which first became evident in
^lay, 1940. Sale of contraceptives, for example, has
been stopped completely.”

June, IWl

439

GONORRHEA IN THE FEMALE— DEAKIN AND SMITH

Gonorrhea in the Female’"

By Rogers Deakin, M.D.
and

Dudley R. Smith, M.D.
Saint Louis, Missouri

Rogers Deakin, M.D.

M.D., Washington University School of
Medicine, 1922. Assistant Professor of Clini-
cal Genito-Urinary Surgery, Washington Uni-
versity; Member of the Clinical Cooperative
Group for the Study of Male Gonorrhea; Di-
rector of a demonstration clinic for the State
Board of Health of Missouri at the Washing-
ton University Clinics. Member of the urologic
staffs of: Barnes, St. Louis Maternity, St.
Louis Children’s, DePaul, and Homer Phillips
hospitals.

Dudley Smith, M.D.

M.D., Washington University School of Med-
icine, 1923. Assistant and Instructor in Ob-
stetrics and Gynecology, Washington University
School of Medicine. Chief of Obstetrical
Clinic, Washington University Out-Patient De-
partment. Member, St. Louis Gynecological
Society. Fellow of the American Association
of Obstetricians, Gynecologists and Abdominal
Surgeons.

■ The records of the St. Louis Maternity Hospi-
tal show that up until a short time ago vir-
tually every woman admitted to the wards for
delivery who also was infected with gonorrhea
developed an acute postpartum gonococcal salpin-
gitis about ten days after delivery. Most of these
women had been observed for some months
previously in the outpatient department where
their gonorrhea had been recognized and treated
with mild local therapy.

Such cases have been treated since the first
of the year in the newly organized clinic for
female gonorrhea. This clinic began as a subsid-
iary to an already functioning well-organized
male clinic but now rivals the latter because
of its effectiveness as a treatment agency for
contacts and sources. During these months six
successive women in the first group of 50 cases
of female gonorrhea have been rendered non-
infectious with a single course of sulfathiazole
alone despite their associated pregnancy, have
been delivered and have finished their stay in the
hospital without any clinical or bacteriologic
evidence of gonorrhea.

It will take more than six cases to have con-
vincing evidence of the effectiveness of the
treatment used but the experience does indicate

*From the Washington University Clinics, Saint Louis, Mis-
souri, in cooperation with the State Board of Health of Missouri.

Presented before the Ingham County Medical Society as part
of the Fall Symposium on Gonorrhea, 1940.

the promise which sulfathiazole gives for the
ultimate control of female gonorrhea.

The women under study in this clinic are
ambulatory patients. They are under no obliga-
tion to come for examination and under no
coercion to receive treatment or to continue un-
der observation for the four months which the
routine requires. The lapse rate from observa-
tion (10 per cent) is extremely low, however,
due to the intensive caseholding and casefinding
technics which are available. Over fifty unse-
lected cases of female gonorrhea confirmed by
culture have now received a single course of 20
grams of sulfathiazole at the rate of 4 grams a
day for five days. Six out of the first fifty have
had one repeat course. No other therapy, oral
or local, has been used. Each woman returns
once a week for 3 weeks to be examined and to
have smears and cultures made from the urethra
and cervix. If negative reports are obtained, she
then returns for the same procedure once a month
for 3 months before dismissal.

The most important consideration (Fig. 1)
is the consistency with which the cases are
rendered non-infectious at the end of this five-
day treatment period. Rapid sterilization of
the gonococcal infection in a woman is of
paramount importance for at least three rea-
sons: (1) to prevent spread of infection to
the male, (2) to prevent the complications in
women which so frequently occur from gon-
orrhea at the time of menstruation and (3) to
decrease the incidence of gonorrheal ophthal-
mia.

It would appear that in sulfathiazole we have
an effective agent with which to accomplish this
rapid change from an infectious to a non-infec-
tious state without fear of any untoward reac-
tions. It has not been necessary to stop or de-
crease the amount of drug given any patient in
this series because of toxic side reactions
although about half of the cases have complained
of some transient nausea.

The accumulated experience with sulfonamide
therapy in gonorrhea is most impressive in one
regard, namely to limit sharply the time interval
during which sulfonamide treatment is given a
trial. The best interests of the patient are not
served by continuing sulfathiazole or any sulfon-
amide much over a week’s time. It can be said

440

Tour. M.S.M.S.

GONORRHEA IN THE FEMALE— DEAKIN AND SMITH

now without equivocation that if the desired
result is not obtained quickly, it more than likely
will not be obtained at all. As a matter of fact,
it would appear that prolonged sulfonamide ad-
ministration prevents the development of an
immunity response to the gonococcus. Certainly,
a patient suffering from anorexia, loss of weight
and perhaps an anemia, the result of prolonged
sulfonamide therapy, is not in the best condition
to throw off a gonococcal infection.

One of the most gratifying developments of
sulfonamide therapy in gonorrhea deals with the
abandonment of local treatment. It has always
been difficult to justify the use of many forms
of local manipulation or application in female
gonorrhea. This has been true of the chemically
irritant drugs and the mechanically traumatizing
procedures in both male and female. It has been
particularly true of the many unnecessary and
unwarranted operations to which women with
acute gonococcal salpingitis have been subjected.

Much credit is due those who, even in the
pre-sulfonamide era of gonorrheal therapy, in-
sisted that local treatment to the female should
be confined to douching or vaginal irrigations
with weak permanganate or lactic acid solutions
warmed to body temperature. At least, this did
not interfere with the body defense mechanism
against the gonococcus if the douche was taken
properly; i.e., in a recumbent position and under
low pressure.

The rationale for a weak acid douche such as
1 :2000 lactic acid is based on the pH studies of
vaginal and cervical secretions. The endocervical
glands produce an alkaline secretion while the
vagina is normally acid. A gonococcal endocervi-
citis accentuates the production of alkaline secre-
tions which get into the vagina. The growth of
the Doderlein bacillus, a normal inhabitant of the
vagina, is discouraged by an alkaline environ-
ment and many observers feel that growth of this
bacillus deters the growth of the gonococcus.

The initial stage of female gonorrhea is an
invasion of the external genitals and urethra
accompanied by an intense inflammatory reaction
of mucosal surfaces. This is followed by invasion
of one or more of the structures lined with
columnar epithelium such as Skene’s, Bartholin’s
or the cervical glands. Even the mildest sort of
douching is not logical in this stage of infection.
On the other hand, oral medication should be
started immediately. Unfortunately, few women

recognize an early gonorrhea for what it is and
seek medical service. The usual patient is first
seen after this active invasive phase has partially
subsided into the second or colonizing phase of
infection or has progressed to a more chronic
third phase of general pelvic involvement.

The second stage, in the light of our present
experience, still offers an opportunity for sul-
fathiazole therapy. The mild douches previously
described may be withheld unless oral treatment
fails to render the patient non-infectious. The
cervix offers the last barrier between a gonococ-
cal invasion of the lower pelvic structures and
the upper pelvic structures or tubal and peri-
toneal zones. Hence, nothing of a traumatic
nature should be done to disturb the defensive
properties of the cervical glands at this stage.
Sulfathiazole failure cases in the colonizing type
of infection are handled best by resorting to a
thorough trial with permanganate or lactic acid
douches. A persistent Skenitis or endocervicitis
which does not respond to either oral or local
therapy as described calls for the eradication of
the gonococcal focus by more intensive means.
Destruction of the infected gland bearing area
by the various chemical or physical modalities
usually employed is a logical and effective means
of achieving a cure under such circumstances.

The suggestions made by the female section
of the American Neisserian Medical Society
in 1940 regarding acute gonococcal pelvic in-
flammation are worth repeating. They call
for general medical care, rest in bed, heat or
cold to the lower abdomen, regular intestinal
elimination, liquid or soft diet, no alcohol,
anodynes for pain and avoidance of all trauma.
The addition of a course of sulfathiazole to
the above regime seems warranted although
again we would limit the treatment period to
approximately five days.

Chronic pelvic inflammation calls for the same
consideration. Sulfathiazole will render the ma-
jority of such cases non-infectious. However,
the pelvic adhesions which are present may pre-
vent the patient’s becoming asymptomatic. This
seems to be true particularly of those women who
have borne children and who have a retroversion.
Here, pelvic surgery seems to offer the only
chance for complete alleviation of the chronic
invalidism induced by the mechanical abnormali-
ties present in the pelvis, either with or without
specific infection.

June, 1941

441

THERAPY- LOCAL: noh. ORAL: SULFATHI AZOLE (winthrop) Four graas dally for five days

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442

Jour. M.S.M.S.

GONORRHEA IN THE FEMALE— DEAKIN AND SMITH

The reasons for failure in the treatment of
gonorrhea result for the most part from negli-
gence on the part of the patient, lack of coopera-
tion in any treatment scheme, ignorance, over-
treatment and the injudicious use of sulfona-
mides. The latter is excusable because of the
rapidity with which these drugs have come into
use. It has long been recognized, however, that
gonorrhea is fundamentally a self-limited disease.
Over-treatment, therefore, only serves to nullify
nature’s efforts to effect a cure. Negligence on
the part of the patient is usually due to ignor-
ance and therefore responsive to education.
Again, education is our best weapon to control
the incorrigible patient.

The wide variability of the problems of the
woman with gonorrhea make women more diffi-
cult to control than male patients. Yet, some of
the most gratifying instances of response to such
psycho-therapy as we have to offer the incorrigi-
ble patient come in the female group.

It seems quite likely that the number of sul-
fonamide-resistant cases of female gonorrhea
will increase as time goes on. Unauthorized self-
medication or improper sulfonamide therapy al-
ready presents a difficult problem in male gonor-
rhea. We feel that sulfathiazole therapy should
not be continued for more than 5 days and that
the course should not be repeated in the event of
relapse. The rapidity with which the great ma-
jority of cases respond to sulfathiazole strongly
suggests that nothing is to be gained by continu-
ing to give the drug to those few cases which
remain infectious at the expiration of five days
of treatment or to those in whom relapse oc-
curs. Previous experience with the chronicity of
sulfanilamide resistant cases in the male would
support this opinion. We have repeated the
course in a few instances where there was a re-
turn of the infection. In most of these cases,
subsequent investigation of the patient and her
contacts would indicate that the return was in all
probability a reinfection after exposure with a
known infectious source.

A large portion of our sulfathiazole failures
are in men who have been on sulfanilamide pre-
viously without benefit. Our routine requires
delaying the use of sulfathiazole in such instances
until there is reasonable assurance that any in-
hibiting influence from previous sulfonamide
therapy is gone. This is judged by the time
elapsing since the previous chemotherapy, by

the physical condition of the patient and the type
and extent of his or her infection. This interval
of time during which sulfathiazole therapy is
withheld offers an opportunity to improve the
patient’s nutrition and general resistance by
means of a high caloric, high vitamin diet and
the stimulating effects of conservative local treat-
ment.

We have not resorted to hyperpyrexia in a re-
fractory female infection though we have made
use of fever therapy in a few instances of stub-
born infections or cases with severe complica-
tions in the male. It is our opinion that fever
therapy should be reserved for such cases and
with a considerable confidence as to the outcome.
Also, it is our belief that the more sulfonamide
has been given to a sulfonamide failure, the less
responsive he will be to fever therapy.

It is our impression that the patient who has
remained clinically and bacteriologically negative
for several weeks after sulfathiazole therapy was
stopped probably has been cured. A return of
the symptoms and bacteriologic evidence of gon-
orrhea after such an interval is usually consid-
ered as a relapse and was so recorded in Cases
3, 17, 41, 45, and 46 (Fig. 1). However, in each
of these cases a comparison of the patient’s his-
tory with that of her consort would suggest that
re-exposure and reinfection was either certain or
at least extremely probable.

The return after an interval of several weeks
of clinical evidence of infection without confirma-
tion by smear or culture has been noted repeat-
edly in our series. Vaginal inflammation and
discharge reappear in these cases but the cultures
remain negative. Smears are apt to be mislead-
ing because of the variety of organisms encoun-
tered. Without culture facilities, the natural in-
clination of the physician would be to consider
this as a relapse. However, the consistency with
which negative gonococcal cultures are obtained
in these cases lead us to believe that a nonspecific
bacterial process is reasserting itself after an
initial bacteriostatic sulfathiazole effect has worn
off. Lactic acid douches have been successful in
overcoming this complication.

Until such time as a central statistical agency
is established for the accurate evaluation of the
chemotherapy of female gonorrhea, extreme cau-
tion will have to be exercised in the prognosis
given to female gonorrheics. Too many variables
are present to make a number of isolated reports

June, 1941

443

GONORRHEA IN THE MALE— PELOUZE

of small groups of patients very significant.
The adoption of a standard record form and its
use in treatment centers would expedite the ac-
cumulation of sufficient data in a central statisti-
cal agency upon which to draw accurate con-
clusions.

The substitution of chemotherapy for local
therapy as much as possible on the principle
that a gonococcal infection is fundamentally
a constitutional rather than a local disorder is
also now in order. The fact that the mani-
festations of a female gonorrhea are for the
most part confined to local processes in the
genital tract does not detract from this ap-
proach to therapy. Once the possibilities of
specific chemotherapy have been thoroughly
canvassed, then better agreement may be had
as to when and what local treatment should
be used in the event of chemotherapeutic fail-
ure.

The control of gonorrhea is predicated upon
an effective treatment of female gonorrhea.
There is every reason to believe that with sulfa-
thiazole we approach the ideal of a rapid sterili-
zation of gonococcal infections in the female by
means of oral medication alone. This does not
imply, however, that a patient may disregard the
ordinary rules of behavior laid down for a gon-
orrheic or that the physician is relieved of his
responsibility to the patient during oral therapy
or until there is reasonable assurance of cure.

Note: The sulfathiazole used in this study was fur-
nished by the Department of Medical Research of the
Winthrop Chemical Company, New York City.

BLITZKRIEG ON SYPHIUS

At the Annual Meeting in Grand Rapids this fall,
Loren Shaffer of Detroit will tell you how some cases
of syphilis may be cured in less than a week; if you
attend the meetings of the Section on Dermatology and
Syphilology.

The officers of the Section announce that this is only
one of the valuable and practical papers for which they
havfe arranged to help you handle your dermatological
patient.

Doctor Shaffer has been conducting clinics at the
Receiving and Providence Hospitals in Detroit in which
the new “massive chemotherapy” method is used. This
work has been done in collaboration with other clinics
and you will be given a clear comprehensive report on
its technique and results.

; The Section officers believe that if you treat syphilis
.you owe it to your patients and yourself to hear this
paper.

•444

Gonorrhea in the Male*

Modern Treatment

By P. S. Pelouze, M.D.
Philadelphia, Pennsylvania

M.D. Jefferson Medical College 1902 As-
sistant Professor of Urology at University
of Pennsylvania. Fellow, Philadelphia Col-
Physicians. Member, American
Urological Association. Member Executive
Committee of the American N eisserian Med-
tcal Society. Member, Board of Directors
of the American Social Hygiene Association.
Member, Research Advisory Committee for
the New York City Board of Health; and
National Committee on Venereal Disease
prophylaxis. Chairman, Cooperative Clinical
Lpmnuttee for the Study of Gonorrhea. Spe-
cml Consultant to the United States Public
Health Service.^ Associate Editor of Clyco-
pedta of Medicine Surgery and the Special-
ties. Member, Editonal Advisory Board for
Journal of Syphilis, Gonorrhea and the Ve-
nereal Diseases.

After a long, long sleep it is obvious that
something really is going to be done toward
the control of gonorrhea. Within the last few
years things have been happening that have
overcome many of the barriers that stood in
the way of this disease making the grade from
the sin class into those upper reaches where a
disease is really a disease. Indeed, one who
watches his step just a little, can even make it
table talk in polite society. And, when a disease
reaches that point just about every physician is
better off if he takes time to really learn enough
about it to fit him for the giving of sensible
answers to the countless questions sure to come
his way.

It has not been the custom of physicians to
pay much attention to clinical behavior of this
disease. To a large extent the sole cry has been,
“How should it be treated?” As the result of
this attitude on the part of the general practi-
tioner and an unfortunate lack of real interest
upon the part of most urologists there has even-
tuated a decided shortage of men sufficiently
versed in the entire subject of gonorrhea to
furnish us with the teachers that are sorelv
needed for the education of the public and the
medical profession as well. This shortage of
qualified teachers who can discuss all phases of
gonorrhea is being particularly felt at the pres-
ent time when vast numbers of our young men
are entering the various protective services of

^Presented before the Ingham County Medical Society as
part of the Fall Symposium on Gonorrhea, 1940.

Jour. M.S.M.S.

GONORRHEA IN THE \LALE— PELOUZE

the government. The strain that this shortage
has thrown upon those few who have not made
a one-sided approach in their understanding of
gonorrhea and who have had the courage to
openly espouse the battle is far greater than is
generally recognized. It is a condition crying
for immediate correction.

Lest someone suspect that the statement
that our profession has not kept pace with
modem thought concerning the clinical as-
pects of this disease is unfounded, considera-
tion might be directed to what justly can be
called the “sulfanilamide fiasco” and the thera-
peutic confusion that has followed. The pro-
duction of this confusion, sad to state, must be
laid at the door of our urologists. For it was
they who carried out the early clinical trials
upon sulfanilamide and wrote such glowing
stories about the results they thought they ob-
tained. They told us that this dmg produced
for them anywhere from 50 to 95 per cent of
cures in ambulatory patients. We, and they,
now know that this is not the case and that one
must be generous to a most unscientific fault
to attribute to this particular drug as high as
a 30 per cent apparent cure rate.

The analytic mind naturally wonders how
supposed specialists upon this disease could have
misled themselves and others so greatly. And
when one delves into the real reason for it all
he is sure to find that a poor understanding of
the true clinical course under var}dng condi-
tions and in various individuals was the main
reason. In other words, these investigators en-
tirely lost sight of the time element in a disease
that eventually gets well of itself in most well-
behaved males. They failed to recognize that
patients who harbored the gonococcus after a
few weeks of sulfanilamide medication and even-
tually got well, did so because it was in them to
muster up the required immunity responses
spontaneously or as the result of the stimulating
effects of concurrently used local treatment and
not because they had been consuming sulfanila-
mide. Erroneously they included in their re-
ported figures drug cures, local treatment cures
and even time-element cures and the figures
looked fine. Only those who really knew gon-
orrhea failed to be fooled into making such in-
terpretations. Those who investigated the action

of sulfanilamide in pneumonia made no such
mistakes.

The memory of this unfortunate experience
should teach us much. At least, it should
show us that he who knows little or nothing
about the disease itself is rather poorly
equipped to evaluate treatment methods or to
carry them out. It should convince us that
the time is here when every physician who
treats gonorrhea should get his mind off of
the sole question of treatment long enough
to familiarize himself with the clinical
aspects of the disease he is treating. Public
safety demands it and professional reputation
urges just as strongly the wisdom of such
a move.

And, as we are overcoming this deficiency, we
might do well to stimulate in ourselves a degree
of social vision that leads us to see in every pa-
tient with the disease not only someone who
needs treatment but an individual from whom
Society must be protected until we have excel-
lent reason to believe that the disease has been
cured. Also, we owe it to humankind to real-
ize that our patients acquired the disease from
others and that, unless we make a real effort
to see that these disease sources are placed un-
der treatment, we are doing rather a poor job in
public health.

In view of the fact that every State Depart-
ment of Health has been instructed by the United
States Public Health SerA'ice, from whom funds
are being allotted for the venereal disease con-
trol program, that a part of these funds must be
used for the control of gonorrhea, we might do
well as a profession to realize that the fight at
last is on. Standing, as we do, at the inter-
section of all such endeavors, we also must
realize that a large part of such work falls
upon our shoulders.

Not only must we prepare ourselves but we
have just as an important part to play in pub-
lic education. No one can do this as we can
and one only has to study the results of recent
surveys as to where young men advised in-
quirers to go for treatment to discover that
we do not stand so high in their estimation
as should be the case.f For most of them

tSee Venereal Disease Information, January, 1940.

Tune, 1941

445

GONORRHEA IN THE MALE— PELOUZE

advised that the supposed sufferers go to a
drug store. Fewer of them suggested a
clinic, while the private physician came in as
rather a poor third. Of course, these in-
quiries were not made among the most in-
telligent of our citizens, but gonorrhea is
far more prevalent among those who were
asked than it is among the better educated.

However, our supposed intelligentsia do not
always seek sexual relief among their more
intelligent sisters. So the gonococcus goes back
and forth between all so-called strata of society
and neither is protected unless all are included.

As a profession we might do well to realize
that Congress was moved to make the appropria-
tion of funds for the control of the so-called
venereal diseases largely by what it was told
about the ravages of syphilis among what we
have come to call that “great underprivileged
third” of our population. It was not greatly
concerned about those who were reputed to
wear “white collars.” Such being the case, we
might do well to analyze at least one of the
ideas rather widely held about those to whom
Congress extended its sympathy. In doing this
let us stick solely to the question of gonorrhea,
for it is possible that one cannot make such
positive statements about those of our poor and
near-poor so far as syphilis is concerned. In
these days of limited medical incomes it is only
natural that the question of the abuse of free
and small-pay dispensaries should receive at-
tention. And one commonly hears criticism
raised about the question. Even casual ques-
tioning of those who attend such dispensaries
for the treatment of gonorrhea will show that
there is so little such abuse that it can be com-
pletely disregarded. There is no disease about
which men are' more secretive, and those who
possibly could pay for private treatment do not
frequent such dispensaries — they go to either
the druggist or the physician’s office. Upon a
number of occasions the writer has had such
an investigation carried out in his dispensary
and about the only times patients were found
who could pay for treatment, they had been sent
to the dispensary by physicians. In brief, this
field of endeavor entails no economic loss to
our profession and we would do best to forget
economic outlook in this regard, rejoice over
the fact that these people can have treatment

placed within their financial reach and do all we
can to encourage those who run them and
those who must attend. Indeed, if we are really
interested in control, we might encourage them
to go there instead of to the druggist, for it has
been shown by a recent nation-wide survey that
only 7 per cent of our druggists refuse to make
a diagnosis, treat or sell remedies for gonorrhea.

Treatment

So much for these highly important things
that are hampering success in the control of
gonorrhea. Let us now consider where we stand
on the matter of treatment itself. Recent ad-
vances have placed us in a decidedly attractive
position in this regard. Out of the welter of
therapeutic confusion has emerged a set of con-
ditions that lend themselves well to the laying
down of a number of rules and near-rules that
should do much to clear the atmosphere and
which, if constantly borne in mind, will make it
possible for us to eradicate more gonorrhea in
the next few years than has been done in any
fifty years of the world’s history. True, we
have not reached the point of therapeutic per-
fection, but we have in our hands today chemo-
therapeutic agents that surpass in value any-
thing the most optimistic of us ever expected to
possess and it is more than possible that there
are better things yet to come.

To date there are three widely used sulfona-
mide drugs on sale for the treatment of gonor-
rhea— sulfanilamide, sulfapyridine and sulfa-
thiazole. And it might be well to discuss them
briefly in this order in the light of our present
knowledge to the end that we get the most out
of them with the least harm to our patients.

Sulfanilamide. — This drug does one of three
things for and to patients with gonorrhea, viz. :
(1) it cures some, (2) it makes symptomless
carriers of some and (3) it fails to have any
influence whatever on others. Its apparent cure
rate is so low in comparison with the other two
sulfonamide drugs that many careful clinicians
are convinced that we would do best if we
stopped using it for this disease. This cure rate
in ambulatory patients is not above 30 per cent
and the rest are failures. Its toxicity rate is at
least 50 per cent.

446

Jour. M.S.M.S.

GONORRHEA IN THE MALE— PELOUZE

Stdfapyridine. — This compound, dose for dose,
is about as toxic as sulfanilamide. Its apparent
cure rate is from two and a half to three times
greater and it has an attractively low carrier rate.

Sulfathiazole. — Unquestionably this is the bet-
ter drug of the three in the treatment of gonor-
rhea owing to its far lower toxicity rate. Its
therapeutic value is in every way equal to that
of sulfapyridine.

Before enumerating our rules and near-rules
it is appropriate to spend a little time on that
highly important question of carriers. Such in-
dividuals, though they still harbor the gonococ-
cus and can transmit it to others, have absolutely
no symptoms to suggest its presence. They usu-
ally can indulge in all of those things so potent
in the production of symptoms in latent cases in
the old presulfonamide days, without the slight-
est return of symptoms. When they transmit
the disease to others most, if not all of their
victims, become totally asymptomatic carriers.
They have not the slightest reason to suspect
thay have been infected, though careful micro-
scopic or cultural studies will reveal the pres-
ence of the gonococcus. When these secondarily
infected individuals transmit their infections to
a third party he is left in no doubt about the
matter of infection — he has a frank attack of
the disease. Socially, these primary and sec-
ondary carriers are our greatest present-day
therapeutic concern. Our further interest in the
really cured ceases, we are not fooled by those
who fail of any benefit, but we can be unmerci-
fully deceived by those who still have the disease
and, yet, present no clinical evidences of it. The
difficulty in the pronouncement of cure is now
our chief concern in all but the definite drug
failures who must be treated by those methods
in vogue before we had these drugs. For some
few carriers escape detection despite the most
careful tests for cure which include repeated
microscopic and cultural studies.

1. High blood concentration of the sulfona-
mide drugs is not needed in the treatment of
urogenital gonorrhea — some of the greatest suc-
cesses have been in patients in whom this went
no higher than 1.5 mgm. per 100 c.c. of blood
and some of the most signal failures occurred
where it reached 15.0 mgm.

2. If sulfonamide drugs are acting favorably,
the patient should be entirely symptom-free by

the end of the fifth day. If this has not oc-
curred he can be classed as a definite drug fail-
ure and medication with that particular sulfona-
mide should be discontinued.

3. Such patients should, after a few days’
rest, be placed on another sulfonamide and, fail-
ing of benefit from it, should be placed on local
treatment.

4. Sulfanilamide failures rather commonly are
favorably influenced by the other two drugs but
the reverse is not the case. Sulfathiazole, not
uncommonly acts favorably in sulfapyridine fail-
ures.

5. Present custom is to discontinue the sul-
fonamides after a week or ten days. There is
nothing to suggest that longer medication is
needed or is of value.

6. There are many useful schemes of dosage
none of which aim at high blood concentration.
The following have been employed by different
careful clinicians with about equal curative re-
sults.

Days 12 3

Grams 3 3 3

Grams 4 3 3

Grams 3 3 2

4 5 6 7
3 3 3 3
2 2 2 2
2 2 2 2

8 9 10

2 2 2

2 2 2

7. In these dosages and shortened periods of
administration the toxic factors are at a low ebb
and with sulfathiazole they are almost nil.

8. This lower dosage for such short periods

is in marked contrast to our first efforts with
sulfanilamide. It greatly reduces the expense
of treatment for the patient and does much to
place it within the reach of the poorer of our
citizens despite the higher cost of the better
drugs. j

9. Despite this lower and shorter dosage the
toxic factors are of sufficient importance to urge
that these drugs should not be given to patients
who cannot be seen by the physician at 48- or
72-hour intervals at most.

10. In those seemingly cured our older tests
of cure are of little value. They should be stud-
ied repeatedly for some weeks following seem-
ing cure. Even then they should be instructed
not to indulge in unprotected sexual intercourse
for at least two months.

11. It was shown by the studies of the Co-
operative Clinical Group* that, as a criterion of

*Jour. A.M.A. 115; (November 9) 1940.

June, 1941

447

PRIMARY TUBERCULOUS INFECTION— SWEANY

cure, a persistently clear urine for two weeks
or longer was of little value. At least one out
of every three sulfanilamide cases in this category
is still infected. If the most careful microscopic
studies are carried out in such cases this margin
of error falls to one out of twenty who escape
detection. If to these criteria are added careful
cultural studies only one out of a hundred car-
riers will escape detection.

12. By the use of better drugs it is obvious
that we have it in our power to eradicate quickly
most gonococcal infections, if we can keep our
patients under treatment for the required length
of time. Not only should we see that this is
done, but we should insist upon a much longer
observation period after seeming cure than has
been general. In no other way can we reap the
full measure of success and protect others from
that unfortunate carrier-state, the real frequency
of which, no one knows.

Primary Tufaerciilons Infection
In the Adnlt

By Henry C. Sweany, M.D.

Chicago, Illinois

Henry C. Sweany, M.D.

M.D., Rush Medical College, 1921.
Immediately appointed to the Director-
ship of the Municipal Tuberculosis
Sanitarium Laboratory, which position
he now holds. During this time the
staff was binlt up from four to thirty-
two members ( not including twenty-five
volunteers) . In 1929 he was U. S.

delegate to the Pan-American Congress
at Rio and has been appointed again
this year for the same Congress at
Cordova, Argentina. In 1936 he served
as U. S. Delegate to the International
Tuberculosis Union at Lisbon, Portu-
gal. Has been on the National Tuber-
culosis Association Board many times,
and in 1936 was Vice President of the
National Tuberculosis Association.
Member of twelve medical and scientific societies in the U. S.,
including the American College of Physicians, and the American
Medical Association. Has certificates from the American Board
of Internal Medicine and the American Board of Pathology. His
publications include works in pathology and bacteriology of tuber-
culosis, treatment of tuberculosis, non-tuberculous lung diseases,
silicosis, and blood chemistry.

■ The first contact of the tubercle bacillus with
the tissue of the body of a susceptible animal
is remarkably constant in spite of many variable
factors. The uniformity of primary tuberculous
infections was first observed by Parrot in 1876,
many years before the tubercle bacillus was
known. The same phenomenon was reaffirmed

*From the Research Laboratories of the City of Chicago Mu-
nicipal Tuberculosis Sanitarium.

experimentally by Baumgarten, Cohnheim, and
Comet, and in human disease by Kiiss, H. Al-
brecht, E. Albrecht, Ghon, Ranke, and many
others more recently. Parrot’s first observations
were formulated into a law known as the law of
“similar adenopathies” by virtue of the fact that
the lymph nodes leading out from the point of
inoculation towards the blood stream were en-
larged in orderly sequence and in the same
manner. The infection was clearly not alone
one of the local tissues but also one of the lym-
phatic apparatus leading away from the focus
of the origin. The disease was henceforth to be
viewed in the light of most other infections. It
consisted in a local tissue reaction followed by
a progression from one lymph node to another
and terminating in a septicemia when the infec-
tion reached the blood stream. Although this
systemic character of the disease was recognized
by most of the workers mentioned, Ranke® for-
mulated the hematogenous phase into his second
stage. In all he viewed tuberculosis as a disease
of four stages corresponding to what he con-
sidered the principal episodes of the disease.
These stages, are as follows: First, the local

process with the corresponding lymph node in-
volvement— the primary complex; second, the
immediate hematogenous dissemination ; third,
later hematogenous disseminations with begin-
ning organ localization ; and fourth, organ iso-
lated foci. The last two stages are usually ac-
cepted as parts of the third stage, as originally
designated by Ranke. Corresponding to the
morphological stages he proposed an equal num-
ber of stages of allergy or hypersensitiveness of
the body cells to tuberculo-toxin. Others have
carried this schematic effect to an extreme of
doubtful merit when six stages of anergj' and
allergy are described.®

Most conservative workers have felt that
Ranke and his school have been too theoretical
for practical purposes, and prefer to adhere to
the more conservative work of Parrot, Kiiss,
and Ghon.

Irrespective of different interpretations, the
following facts are generally agreed upon by
the majority of workers. The infection begins
as a local bronchopneumonia, and the lymph
nodes in anatomical relation are soon involved.
This is followed by a hematogenous dissem-
ination to the lungs and then to the whole

448

Tour. M.S.M.S.

PRIMARY TUBERCULOUS INFECTION— SWEANY

system. Later these systemic foci may de-
velop into disease of the respective organs.
The lesions may spread into advanced disease
or may become encapsulated, calcified and
later resorbed.

It is a notable fact, however, that practically
all the conceptions of primary tuberculous in-
fections have been founded upon the observa-
tion made in children. Practically nothing
has been contributed for primary infections
in the adult.

The principal reason for this lapse seems to
be an oversight rather than a lack of observa-
tion. Blumenberg^ was one of the first to point
out what appeared to be a discrepancy in the
classical type of primary lesion in adults. Sim-
ilar phenomena appeared to me^^ entirely with-
out knowledge of Blumenberg’s work. The ob-
servations of Soper and Amberson,^^ Myers,®
Stiehm,^® annd other clinicians support the hy-
pothesis that many primary infections take place
in the adult, although all adult lesions appearing
as the tuberculin reaction turns positive, correct-
ly have not been accepted as primary. The
turning positive of the tuberculin reaction at
about the time the lesions appear, does not rule
out an earlier extinct infection.

The important feature is that pathologically
there are rarely found any older lesions than
the ones appearing with the positive tuberculin
reaction. Although very small lesions may have
been overlooked or have become resorbed, the
fact that no older calcifications are found justifies
the assumption that the cases are to be classed
as essentially primary infections.

Since there has been so little written on pri-
mary tuberculous infection in the adult, an in-
quiry into the subject will be pertinent. Surely
in the thousands of necropsies over the last sixty
years many should have been on adult patients
with a first infection. This is especially true
in the last two decades. A glance at table I
will show the reasons for this assumption. Even
sixteen years ago Slater^^ found only about 10
per cent of rural children in Minnesota to be
infected by high school age — a rate below 1 per
cent a year. Chadwick and Zacks® found the
infection rate to be 1.5 per cent a year for Bos-
ton, which is a fairly representative large city.
Detroit, Chicago, and Minneapolis have been
found to have similar rates of infection. At a

1.5 per cent rate there are only approximately
90 per cent infected by sixty years of age. As-
suming that the rate is constant, there would
be only 30 per cent by twenty years of age,
leaving 60 per cent in adult life, with 10 per
cent escaping infection altogether.

Tuberculin surveys in Chicago as well as
elsewhere reveal an average of only about 30
per cent infection by the end of high school
life. If these calculations are even only ap-
proximately correct, we are forced to the
startling conclusion that over half of the in-
fections in many civilized communities today
take place in adult life, and that most of
the cases appearing in patients whose tuber-
culin test turns positive with the appearance
of the lesions, are primary infections.

TABLE I. HYPOTHETICAL SHIFT FROM YOUNGER TO
OLDER AGE GROUPS AS THE INFECTION
RATE INCREASES

Infection
Rate per Year

Years

Per cent
Infected in
Childhood

Per cent
Infected in
Adult Life

8%— 100% by

12.5

100

0

5%— 100% by

20

70

30

3%— 100% by

33

42

58

2%— 100% by

50

28

72

1.5%— 91% by

60

21

70

1.0%— 60% by

60

14

46

A logical query that follows is why do not
more pathologists report the observation? The
principal reason appears to be that pathologists
are not justified in recognizing any primary le-
sion as such that is not a classical primary com-
plex. Pathological criteria must be largely on
the basis of morphology. But are there not
circumstances that may alter the classical pic-
ture of Parrot, Ghon and Ranke?

In order to investigate the problem a special
study has been made of our postmortem mate-
rial. All the cases have been chosen in which
there was a definite single contact history with
the age character of the lesions corroborating
the contact. Lesions were chosen which were
the oldest calcified lesions found in the body
after a careful search with the x-ray. The

June, 1941

449

PRIMARY TUBERCULOUS INFECTION— SWEANY

TABLE II. CHANGES IN “vOLUME” IN CUBIC MILLIMETERS IN THE COMPONENTS OF
PRIMARY LESIONS AS AGE ADVANCED IN A SERIES OF KNOWN SEVERE CONTACTS

Age

Period

Number

of

Cases

Average

Volume

Parenchymal

Lesions

Average
Volume
Bronchial
Node Lesions

Average Volume
Tracheal-Bronchial
and Tracheal
Lesions

Total

Lymph Node
L^ions

0- 5

11

210

450

1,350

1,800

6-10

9

87

555

805

1,360

11-15

9

31

92

137

229

16-20

10

33

73

12

85

204-

5

9

16

6

22

cases' were then divided into 5-year age periods
and the calcified lesions of the parenchyma and
the lymph nodes, respectively, were measured
on the postmortem x-rays, averaged for each
group, and tabulated in table II. A glance at
Table II reveals that there is a gradually de-
creasing size of the lymh node complex as the
patient approaches adult life. Many of the le-
sions in adults would be overlooked entirely
without postmortem x-rays and a painstaking
search. Many adults do not have lymph node
involvement at all. In addition there is prone
-to be smaller parenchymal lesions in the fatal
cases. The exceptions to this were in Negroes
whose disease approached more that of the
childhood type, as shown by Opie® and others.

Another observation was that the lesions of
adults predominated in the upper parts of the
lungs. On microscopical study it was also note-
worthy in a large number of cases that the cap-
sules were not well developed and that calcifica-
tion was slower in forming. Finally, in Table
III is shown a tendency for the disease to run
a more rapid course in patients dying after 15
years of age after the first infection evolves
into active disease. If all fatal cases are counted
and not just those dying after 15 years of age,
this difference may be only less or even may
not exist at all. It does show, however, that
the greater number of adult lesions that progress
do so rapidly and the critical period is in the
young adult in which most fatalities are found.

To illustrate these various forms, several cases
have been selected and will be reported briefly,
beginning with the lesions wherein the lymph
node components are typical, although usually
smaller than the parenchymal foci and proceed-
ing to the cases that are more atypical.

.450

Case 1. — M. I. (A866) Avas eighteen years old at
death, and was exposed to his father about a year
earlier. There was a small typical primary lesion in
the right base that followed the lymph nodes to the
hilum and across to the left superior tracheobronchials.
They ranged from 2 to 5 mm. in diameter. One
of the superior tracheobronchial nodes ruptured
through the mediastinum into the left upper limg
lobe leading to a terminal tuberculous bronchopneu-
monia. The lesions were small, soft and of the class-
ical type, but there was no preponderance of either.
They were of a one and a half year type.

Case 2. — L. S. (A544) was a twenty-nine-year-old
nurse on whom a calcified lesion appeared on the
x-ray about six years before death. A parenchymal
extension appeared around the calcified lesion five years
before death, and a diagnosis of tuberculosis was made.
The disease progressed to death, and at the autopsy
a typical primary complex was found, but there Avas
no extension beyond the bronchopulmonary nodes near
the hilum. The size of the parenchymal lesion was
about 5 mm. and the three bronchopulmonary nodes
from 3 to 7 mm. in diameter. The age character of
the lesions was of a six-year type.

Case 3. — H. E. H. (A1140) was an American male,
thirty-seven years old at the time of his death. The
onset of his disease was in 1930. He was admitted to
the sanitarium on three occasions and died in 1938
of pulmonary tuberculosis. There was a fibroid cavity
in the left upper and a small soft-walled one in the
lingula which produced a bronchopleural fistula and
empyema. There were a few parenchymal calcifications
in the right upper lobe and in both bases. A huge
calcification was found in the right paratracheal nodes,
a soft calcified mass in the liver, with several satelite
colonies, and about a dozen 2 to 3 mm. tubercles in
the spleen. The age character was estimated as of an
eight-year type.

Case 4. — L. C. (A1197) was a twenty-four-year-old
female at death. There was a rather large primary
complex in the right upper lung lobe (5 mm.), a larger
one in the bronchopulmonary nodes (7 mm.), and

Jour. M.S.M.S.

PRIMARY TUBERCULOUS INFECTION— SWEANY

TABLE III. COMPARISON OF THE DURATION OF THE CLINICAL DISEASE AND LATENT
PERIOD IN VARIOUS AGE GROUPS OF A SERIES OF SEVERE CONTACTS
DYING AFTER 15 YEARS OF AGE

Age Limits
of

Infection

(years)

Number

Average
Years of
Clinical
Disease

Average
Years of
Latent
Period

Total

Disease

Period

Average
Age at
Death

1- 5

14

6.1

18.5

24.6

27.1

6-10

18

3.4

12.6

16.0

23.5

11-15

' 23

2.8

7.8

10.6

23.1

16-20

14

2.1

5.9

8.0

25.5

20-26

9

4.0

3.5

7.5

30.0

Grand Average

78

3.0

10.0

13.5

25.8

one still laxger (10 mm.) in the hilum nodes. There
^\"as a hematogenous spread to the spleen. The lesions
were from three to six years old in appearance.

Case 5. — M. S. (A1302) a Even t}*- six-year-old

Negro woman born in Alississippi and came to Chicago
when she was twenty-one years old. She did house-
work before and after marriage. She has had two mis-
carriages.

The onset of her disease was influenzal in August,
1939, and death occurred in May, 1940. Her cough,
volume of sputum and fever increased imtil death.
At the autopsy many small recent (3-4 year) lesions
were found in the limg parenchyma with evidence of
“overflow” into large infiltrates which ulcerated and
led to extension of her disease. There were lymph
node lesions aroimd the hilum measuring 3 to 4 mm.
in diameter. They were slightly larger than the paren-
chymal lesions but still smaller than are usually foimd
in children. Some of these lesions also revealed a
tendency to overflow the original boundaries.

This patient was apparently infected soon after com-
ing to Chicago, the lesions then progressed for two
or three years without noticeable symptoms and on
to clinical symptoms nine months before death.

Case 6. — G. C. (A873) was a thirty-year-old white
woman at death, which resulted from an ordinary
pulmonary' tuberculosis. At the autopsy there was a
dry caseous lesion at the hilum lymph nodes of a
three to four-year type. In “anatomical relation” to-
wards the right subapical region was a cavity with
many massive infiltrates in the tissues around. A few
nodular foci were also seen in the left apex.. There
were no other calcified lesions in the body. The pro-
cess was presumptively a massive and continuous pri-
mary lesion in an adult, with an overflowing paren-
chymal lesion having a small lymph node component
at the hilum.

Case 7. — ^J. M. (A358) was a twenty-six -year-old
nurse whose infection was traced to a period near or

during the time of her training course. The disease
began as several small parenchymal foci with a con-
tinuation of the process in the lymph nodes. The
lesions ranged in size from 3 to 5 mm. in diameter.
The clinical process was first observed as a cluster
of cavities in the apex of the right lower lobe and
extended to the base before death. The lesions were
of a six-y^ear type.

Ca^e 8. — S. K. (A652) was a twenty-nine-year-old
white woman who was exposed to her sister seven
years before her own death. There was a “miniature
primary complex” in the right upper and a paratracheal
lymph node in anatomical relation to the oldest fibroid
lesions. The lesions were about 3 mm. in diameter
and did not reach the hilum at all. The process was
of an eight-year type and presumed to be continuous
from the primary.

Case 9. — E. O. (A509) was a thirty-four -year-old
housewife whose clinical disease came on after a
strenuous European trip, five years before death. There
were many parenchymal lesions from three to six mm.
in diameter. The lymph node lesions were small and
did not reach the hilum nodes at all. The age of the
lesions coincided with the illness following the Eu-
ropean trip.

In many instances the lymph node lesions are not
present or are very small. Two cases will be cited.

Case 10. — B. L. (A309) was a twenty-six-year-old
teacher whose infection was probably acquired after
coming to Chicago from Minnesota three years before
death. There was an “abortive” type of primary lesion
with many small parenchymal lesions, many large infil-
trates, and only one one-mm. lymph node lesion in
the bronchopulmonary nodes. They were less than
three year old.

Case 11. — E. B. (A574) \vn.s a twenty-eight-year-old
female who was exposed to her sister eight years
before her own death. There was only a parenchymal
component of the primary of an age character com-

JUNE, 1941

451

PRIMARY TUBERCULOUS INFECTION— SWEAXY

patible with her exposure. No lymph node lesions
were present at all. The lesions were compatible in
character with the exposure.

In attempting- to offer any explanation for
the atypical nature of primary lesions in adults,
the question first arises, -wherein does the adult
differ from the child? First, there is the ana-
tomic change in lymphoid tissue which develops
during the childhood age and atrophies towards
old age. Both of these features would tend to
cause a localization of the bacilli at or near the
site of inoculation as age advances. In addition,
there is the possibility of a “non-specific resist-
ance” that would tend to prevent the bacilli from
going far from the first focus. Although it must
be admitted that such an idea is speculative, it
is within the realm of possibility that age itself,
non-specific immune bodies both humoral and
cellular, and other factors, may assist in the
process of localization of bacilli. While these
theories may assist in explaining why bacilli are
kept from spreading by lymphatics, it does not
hold that tubercles may not spread directly by
an overflow. In fact, highly virulent bacilli
will frequently spread rapidly, particularly in
young adults, into a fulminating disease. Such
rapid spread may well be abetted by a slower
growth of connective tissue as the patient be-
comes older.

DuNiioy,^ experimenting on the healing of
war wounds, showed that wound healing fol-
lows a definite curve from infancy to old age.
A child’s wounds will heal six times as fast
as a similar wound in an old person. While
no proof is extant that shows that tubercles
vary to the same degree as wounds, there is
evidence that during the early phases of tu-
bercle formation the healing process is gen-
erally slower in adult tubercles. The capsules
are frequently thinner, and as a result cal-
cification progresses more slowly, especially
during the first few years. For the same rea-
son, virulent bacilli may spread more rapidly
and lead to progressive disease. Thus the
supposed better resistance of the adult may
be off-set by a slower developing capsule.
The significant feature is that the healing
mechanism only gains momentum after the
bacilli have begun to disappear. During their
greatest gro-wth activity the capsule is most

vulnerable, and this fact may account for the
rapid progression in certain adult infections.

After all the caseous and calcified “primary
complexes” have been taken into consideration,
it apparently still leaves a large number of in-
fections in which no earlier infection could be
found either pathologically or by an x-ray study
of all the common portals of entr}'. There are
many lesions that have no calcifications at all or
the tubercle are not characteristic of priman.'
lesions. There are so many of these lesions
and they have corresponded so closely to the
histories of infection in the respective cases that
there is a strong suspicion that the parenchymal
disease has been too rapid to leave behind any
typical lesions.

A few illustrations will be offered.

Case 12. — C. K. (A390) was a twenty-four-year-old
female exposed to a sister two and a half years before
death. The lesions were quite atypical. There was a
rapid “overflow” of subpleural lesions into large infil-
trates which excavated and produced a “juvenile type”
of disease. Only the bronchopulmonary lymph nodes
were involved in the primary complex. The lymphatic
process was found only by careful study. There were
no calcified lesions found elsewhere in the body.

Case 13. — G. S. (A424) was an eighteen-year-old girl.
She developed symptoms in March and died in Oc-
tober of a fulminating infection largely confined to
the lung parenchyma. The lesions looked even less
like primary lesions than the preceding case. No other
older lesions were found.

Case 14. — E. J. (A752) was a twenty-three-year-old
male at death. He was exposed to a tuberculous sister
seven years before. There was a total excavation of
the left lung. A small tell-tale tymph node at the
hilum gave the only clue to the primary nature and
age of the process. It perhaps began as an overwhelm-
ing pneumonic process.

Case 15. — J. L. (A639) was a similar case in a
twenty-five-year-old housewife, except that only part
of the lung was excavated. In the remaining parts of
the lower there were many calcified caseous foci of
four- to five-year age characteristics which coincided
with a “pneumonia” of that same lung lobe five years
before her death.

These cases illustrate the pneumonic character
of certain tuberculous lesions, some becoming
rapidly fatal, others slowly progressive. None
of them are typical primary lesions, although
it is strongly suggested that the infections were
the first in the body.

452

louR. M.S.M.S.

PRIMARY TUBERCULOUS INFECTION— SWEANY

The cases just cited are not uncommon. If
there is anything unusual it is that the primar}^
characteristics of most of them are overlooked.
The same phenomenon occurs in infants and
children, but in the latter there is usually a def-
inite “lymph node complex” and the age of
the child practically precludes any former in-
fection. In adults they are nearly all accepted
as “reinfection,” because the clinical criteria does
not justify any other conclusion. When post-
mortem x-ray search and gross and pathological
studies fail to reveal any older lesions, however,
the question of the primary nature is raised.
When a history of contact or a clinical episode
corresponds to the character of the lesion, or if
the tuberculin test has recently turned positive,
it makes the primary nature of the condition
more probable.

The cause of this type is not difficult to find
if the observations of heavy dosage or high
virulence is taken into consideration. When
the dosage is large, as shown by SewelP® in
animals, there may be a massive involvement
with primar}’ necrois. The process is usually
so rapid that lymph node involvement may be
slight or lacking.

There are no doubt other rare types such
as those caused by atypical microorganisms,
bovine bacilli, or those changed by diabetes or
silicosis ; but enough has been given to show
that primary lesions in adults of urban life and
habits differ considerably from those found in
children. In more primitive people, however,
as shown by Opie'^ the lesions in adults are not
greatly unlike those found in children. Occa-
sionally such lesions are found in Chicago, but
the percentage is usually small and most of the
lesions seem to be of a progressive lymph node
type usually associated with a variation in the
type of microorganism.

One case of a progressive lymph node type
will be presented.

Case 16. — B. M. (AlOlO) was a thirty-year-old
woman whose disease began seven years before death.
There is no historj’’ of contact, but the oldest lesions
seemed to show about an eight-year process. It was
perhaps two or three years older. From these oldest
lesions there was a continuous overflow into the
lymphatics producing varying ages of hyperplastic
lymph node tuberculosis in the hilum region. Finally
a break through into the parenchyma progressed to a
fatal ending.

Discussion

Although the divergent features of adult pri-
mary tuberculosis would be of great academic
interest alone, they also possess a greater prac-
tical value for the clinician. First of all, the
lesions are frequently small and insignificant
and are prone to be overlooked by the clinician
as of little consequence. No doubt many — ^yes,
the preponderant majority — heal uneventfully,
but enough become malignant that it demands
conservatism in handling any of them. The
worst feature of all is the rapid progress of
the lesions when they get out of the bounds of
the primary localization. Even worse is the
difficulty of keeping the lesions under control
or stopping the process. Chadwick^ has clearly
shown the malignant nature of puberty or young
adult lesions and the difficulty of controlling
them when they become clinically active. It
would seem that these facts help to explain the
course of heav)^ mortality in young adult life,
so long known but always enigmatic. The rea-
sons for the sudden exacerbations of the lesions
in adult life are, perhaps, first a lack of im-
munity that is usually present in those having
had a small infection in childhood or having car-
ried one from childhood; second, a failure of
the natural defensive factors to kill the parasites ;
third, a relatively slower development of the
encapsulating mechanism so well developed in
the young, and lastly perhaps the effect of rapid
growth and change of metabolic and endocrine
development that has just preceded maturity.

In view of the observations reported, it
would seem advisable to be scrupulously care-
ful with any definitely demonstrable lesion in
young adults irrespective of the size. The
only question of importance is to establish
beyond question the tuberculous nature of
any lesion. The problem is not whether the
lesions are large or small. If any lesion ap-
pears, its malignant tendency should be sus-
pected. We should, of course, avoid a cam-
paign of over-diagnosis, but when the lesions’
nature is definitely established it should be
viewed more as we view the presence of ty-
phoid or diphtheria bacilli.

The question then arises, what is the method
of treatment? Naturally, it will not be possible
to intercept every lesion in its barely visible

June, 1941

453

PRIMARY TUBERCULOUS INFECTION— SWEANY

Stage, and if they are intercepted many will dis-
appear or heal uneventfully without the need of
any treatment. The one precept to be followed
is that the presence of a recent lung lesion of
any visible proportions is to be watched; more
particularly, if the tuberculin test has turned
positive at about the same time. These facts
should be kept in mind by the physician, and
it may expedite a diagnosis when clinical symp-
toms appear, and thus the disease may be ap-
prehended in its early stages. The condition
should be explained to the patient and the lesion
may be followed to great advantage by serial
x-rays taken every two or three months until it
has passed the "soft shell stage” of the first two
years. If the lesion is going to show any signs
of spreading, it will unsually do so by that time,
either as a near or distant parenchymal infiltrate
or as bronchial or lymph node phenomena. In
addition, the patient should be advised toi keep
his routine activities within bounds. If another
disease is superimposed, the convalescent period
should be extended longer than normal. This
is especially true following labor in women.
There need be no application of blue laws, but
an adherence to "moderation in all things” may
prevent the spark of infection from reaching
the conflagration of disease.

Summary

In studying the character of primary infec-
tions in adults, it has been noticed that as a
rule they differ from the first infection of child-
hood. There is a tendency for the lesions to
become confined more, to the lung parenchyma,
resulting in a smaller or a total absence of lymph
node components. This may result from the
changing character of the lymphatic anatomy
as age advances. There is an enrichment of
growth of lymphoid tissue in children and later
a gradual atrophy as old age is approached.

There may be a slowly developing non-specific
resistance due to repeated infections as life ad-
vances.

There is also a slower development of the
capsule of the tubercle in adults, which is re-
flected in a thinner capsule, less calcification,
and perhaps a tendency to break more easily and
spread more rapidly. Naturally this tendency
must be off-set by other factors of resistance,
because there are, without much question, as

many or more primar)’ lesions that heal ini
adults as there are in children. ;

The features of value to the clinician are that'
rarely can adult primary lesions be distinguished
clinically from reinfection. Because of this
masking of the lesions, and the fact that the!
process is frequently of a malignant type, it
is well not to neglect adult primary tuberculosis, '
irrespective of the size of the lesions. A more .
vigilant attitude may help to apprehend the dis-
ease before it really gets under way and will
result in the treatment of more minimals and
less far advanced cases, and consequently will ■:
result in fewer fatalities and the return of more
patients to the role of useful citizens.

References

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

Blumenberg, W. : Kritik der Stadienlehre der Tuberkulose

unter besonderer Beruck sichtigung des Sekundarstadiums
Rankes. Beitr. z. Klin. d. Tuberk., 71:385,1921. j

Chadwick, H. D., and Evarts, H. W. : Treatment of pul- ,

monary tuberculosis in adolescents. Am. Rev. Tuberc., 41: <
307, 1940.

Chadwick, H. D., and Zacks, D.: Incidence of tuberculous

infection in school children. New Eng. Jour. Med., 200:
332, 1929.

DuNoiiy, Lecomte, P. : Biological time. New York: The

Macmillan Co., 1937.

Hayek, H. J. : Immunibiologie — Dispositions — und — Kon-

stitutionsforschung — Tuberculose. Berlin, 1921. ;

Myers, J. A. : The first infection type of tuberculosis. 1

Am. Rev. Tuberc., 34:317, 1936. *,

Opie, E. L. : The focal pulmonary tuberculosis of children

and adults. Jour. Exper. Med., 25:855, 1917.

Opie, E. L. : The epidemiology of tuberculosis of Negroes. ^
Am. Rev. Tuberc., 22, 603, 1930. |

Ranke, K. E. : Ausgewahlte Schriften zur Tuberkulo.e — I
pathologie. Berlin, 1928. ^

Sewall, H., and others: The nodules of experimental tu- •

berculosis in the guinea pig and their relations to immunity.
Am. Rev. Tuberc., 26:1, 1932. ^

Slater, S. A.: Results of Pirquet tuberculin tests on 1,654 j

children in a rural community in Minnesota. Am. Rev. .
Tuberc., 10:299, 1924. |

Soper, W. M., and Amberson, J. B., Jr.: Pulmonary tu- |

berculosis in young adults; particularly among medical stu-
dents and nurses. Am. Rev. Tuberc., 39:9, 1939. , *

Stiehm, R. H.: Tuberculosis among University of Wiscon- i

sin students. Am. Rev. Tuberc., 32:171, 1935. J

Sweany, H. C. : Studies on the pathogenesis of primary

tuberculous infection. II Tendencies in adult primary tub-
erculous infection. Am. Rev. Tuberc., 27:575, 1933. i

In answer to the question: “Must students contract .
tuberculosis while in college?” the author answers:
“No, because we have at our command accurate meth- '
ods of screening out contagious cases of tuberculosis in
any group. Therefore, if we keep students under suf-
ficiently close observation, it is with great rarity that
one will enter with contagious disease or will develop
it on the campus so as to disseminate it to other stu-
dents. Thus, the students may be prevented from con-
tracting tuberculosis from one another ... It is true
that the occasional student will become infected
through contact with a contagious case entirely apart
from the campus. However, in most parts of this
country such infections have been reduced to one per
cent or less per year. Therefore, few students become
infected even in this manner while they are in college.”

— Tuberculosis in Slu'd ents by J. Arthur Myers, M.D.,
Anter. Rev. of Tuber., Feb. 1940.

454

Jour. M.S.M.S. j

CYANOSIS OF THE NEWBORN— McKHANN

Cyanosis of the Newborn*

By Charles F. McKhann, M.D.
Ann Arbor, Michigan

Charles F. McKhann, M.D.

S.B., A.M., M.D., University of Cin-
cinnati. Formerly Associate Professor
of Pediatrics and Communicable
Diseases, Harvard University Medical
School and School of Public Health;
Visiting Physician, Infants’ and Chil-
dren’s Hospitals, Boston; Consulting
Physician, Haynes Memorial Hospital
for Contagious Diseases, Boston; and
Cape Cod Hospital, Hyannis, Mass.;
Visiting Professor of Pediatrics, Peiping
Union Medical College, Peiping, China,
1935-36. Newly-appointed Professor of
Pediatrics and Communicable Diseases,
and Chairman of the Department of
Pediatrics and Communicable Diseases,
University of Michigan, 1940. Member:
American Medical Association, Ameri-
can Academy of Pediatrics, American
Pediatric Society, American Society for
Clinical Investigation, Society for Pedi-
atric Research (President, 1936), New
England Pediatric Society, Massachu-
setts Medical Society, American Public
Health Association, American Board of
Pediatrics.

permeability of the alveolar walls, and partial
obstruction of the bronchial tree; (3) proportion
of blood passing from right to left side of the
heart through unaerated channels — affected by
congenital malformations of the heart, atelectasis
and pneumonia; (4) oxygen consumption in the
capillaries — influenced by peripheral vascular
factors.

(£

CL

20

15

10

5

0

MATERNAL

fetal at birth

OXYGEN

CAPACITY

OXYGEN OXYGEN
CONTENT CONTENT
ARTERIAL VENOUS

OXYGEN OXYGEN
CAPACITY CONTENT
ARTERIAL

OXYGEN

CONTENT

VENOUS

* The appearance of cyanosis depends on the
presence in the peripheral circulation of suf-
ficient unoxygenated hemoglobin (reduced) to
impart a bluish color to the skin and mucous
membranes. In the normal adult about one- third
of the blood must be unsaturated with oxygen
before cyanosis appears. Four factors have been
defined by Lundsgaard as affecting the develop-
ment of cyanosis.’’ (1) In the first place stands
the hemoglobin content of the blood. Since the ap-
pearance of cyanosis is dependent on the actual
quantity rather than on the percentage of re-
duced hemoglobin in the peripheral circulation,
it is possible for a patient with a very high
hemoglobin level to be cyanotic and still to have
enough oxygenated hemoglobin present in the
circulation to prevent anoxia to the tissues. On
the contrary, a patient with a low hemoglobin
content in the blood may be suffering from
definite anoxia to the tissues, but the amount of
reduced hemoglobin in the circulation may be so
low as not to cause the appearance of cyanosis.

Only in the presence of hemoglobin levels ade-
quate to permit the development of cyanosis may
the other three factors be operative, viz.: (2)
degree of oxygen unsaturation of arterial blood
coming from aerated lungs — affected by oxygen
tension in the air, rate and depth of respiration,

*From the Department of Pediatrics and Communicable
Diseases, University of Michigan Medical School. Read before
the Seventy-Fifth Annual Meeting of the Michigan State Medical
Society, Detroit, September 25, 1940.

Fig. 1. Normal oxygen relations of maternal and fetal bloods.
This figure shows the average oxygen relations of blood in
fifteen normal mothers and fifteen unanesthetized infants at
birth.

An individual living in an environment of
reduced oxygen tension tends to compensate
by the development of a higher red cell count
and a higher hemoglobin in the blood. It is
doubtful if this compensation extends to a
greater degree than the lowered level of
oxygen tension in the environment requires.
Two examples of such individuals are the
persons living at a high altitude and the fetus
in utero. The added stress to the aviator
going to unaccustomed high altitudes and the
reduction in oxygen supply of the fetus during
the birth process have both the feature in
common of a temporary anoxia. While the
pilot is supplied with extra oxygen, all too
frequently the infant’s insufficient supply is
still further reduced by obstetrical procedures
designed to hasten delivery or to alleviate
pain in the mother.

The comparative oxygen capacities and de-
grees of unsaturation of both arterial and
venous blood of the maternal and fetal circula-
tions are shown in Figure 1 (Eastman).^ It is to
be noted that fetal blood has a compensatory
increase in total hemoglobin associated with a
degree of oxygen unsaturation comparable to or
slightly less than that of maternal venous blood.

June, 1941

455

CYANOSIS OF THE NEWBORN— McKHANN

Thus in utero the fetus may have a physiologic
cyanosis. After birth, the larger amounts of
hemoglobin are no longer needed and blood de-
struction occurs with accompanying physiologic
jaundice (Table I).

TABLE I. CYANOSIS OF THE NEWBORN

Proximal Cause: Oxygen Unsaturation of the Blood
Due to Inadequate Respiratory Exchange.

Underlying Causes:

(1) Cerebral Disturbances

Traumatic

Asphyxia!

Medication

(2) Pulmonary Disturbances

Atelectasis

Obstruction

Pneumonia

Edema

Hemorrhage

(3) Circulatory Disturbances

Congenital Cardiac Anomalies
Peripheral Circulation

Intra-uterine Asphyxia

While still in utero, the fetus, already reacting
to low oxygen supplies, may be subjected to
additional reduction in this necessary gas, which
it cannot further compensate to meet. These
further reductions in oxygen supply produce
intra-uterine asphyxia, perhaps the most im-
portant cause of cyanosis persisting in the new-
born. The causes of intra-uterine asphyxia may
be grouped as follows ; First, any condition which
interferes with adequate oxygenation of the
mother’s blood — a rare cause of this would be
pneumonia in the mother ; an unfortunately com-
mon cause is prolonged anesthesia before and
during delivery.

Secondly, any interference with circulation of
the maternal blood through the placenta, e.g., as
in premature separation of the placenta, infarcts
of the placenta, or with tetanic contraction of
the uterus, induced by pituitrin. Operative here
also is reduction of area of attachment of
placenta following the birth of a twin, sometimes
adversely affecting the oxygen supply of the
second twin.

Thirdly, any condition which impedes circula-
tion through the umbilical cord such as prolapse
or looping of the short cord about the neck of
the baby.

It is obvious that many of these causes of
intra-uterine asphyxia are unavoidable, yet all
may produce the signs of fetal distress, namely,
acceleration and later slowing or gross irregulari-

ty of the fetal heart with appearance of meconium
in the amniotic fluid. Attempts to hasten de-
livery may give rise to the second large cause of
persistent cyanosis in newborn babies, namely,
trauma incident to labor and operative deliver}".
Trauma with gross cerebral hemorrhage occurs
rarely during normal delivery of mature babies,
but is an especial hazard in the delivery of the
premature.

Cerebral hemorrhage attending birth trauma
is usually gross and superficial from tears of
vessels in the falx or tentorium, differing from
the multiple smaller hemorrhages both super-
ficial and deep which commonly follow severe
asphyxia. Not only is the premature baby es-
pecially susceptible to trauma but asphyxial
hemorrhages are also frequently found in the
premature infant. Thus it seems that asphyxia
or trauma of degrees innocuous to full-term
normal infants may produce serious intracranial
lesions in the premature baby. The influence of
sedation and anesthesia as causes of asphyxia
has been well brought out by Eastman,® Clifford,^
Cole,® Smith,®’® and others.

Because it is frequently fetal distress which
leads to operative interference or to efforts to
hasten normal labor, asphyxia and trauma are
often both present as contributory factors in
the cerebral injury in the newborn, yet the
pathologic changes, symptoms, sequelae, and prog-
nosis vary with the preponderance of the one or
the other type of injury. With intra-uterine
asphyxia, congestion, followed by edema,
petechial hemorrhages, and in severe cases gross
hemorrhages, occur. The damage to the brain
in the asphyxiated patient seems to be due not
to the hemorrhage but to the concomitant de-
struction of nerve tissue and damage to blood
vessels, both traceable to the anoxia. Damage
to the brain in cases of trauma seems secondary
to the gross hemorrhage which occurs usually
subdurally, in the subarachnoid space, or in the
ventricles, producing irritation and pessure.

The symptoms characteristic of intracranial
injury are lassitude, vomiting, gross irregula-
rity of respiration, cyanosis, and convulsions.
From the standpoint of cyanosis, hemorrhage
into or over the pons is most serious because
the respiratory center in the brain stem may
be immediately involved. A slowly accumu-
lating gross hemorrhage over the cortex is

4%

Tour. M.S.M.S.

CYANOSIS OF THE NEWBORN— McKHANN

more likely to produce irritation characterized
by convulsions with cyanosis a late sign de-
veloping only when intracranial pressure has
risen. Pressure changes characterized by
fullness or bulging of the fontanelle may be
noted even with mild symptoms in patients
with supratentorial hemorrhages, but with
subtentorial hemorrhage, the condition of the
infant may be grave — without evident pressure
increase.

Even with definite evidence of intracranial
injury, lumbar puncture may be indicated only
in the presence of advancing symptoms. A gross-
ly bloody spinal fluid indicates traumatic hemor-
rhage, while blood-tinged or xanthochromic fluid
indicates either mild subarachnoid or subdural
hemorrhage. Edema may be manifest by pres-
sure increase only.

The prognosis is dependent on the location and
extent of the hemorrhage and brain damage.
Large gross hemorrhages in the subarachnoid
space seem to have a good prognosis unless in
the region of the medulla. A gross hemorrhage
in the subdural space tends to become cystic
and gradually to increase in size, developing into
a chronic subdural hematoma, with disastrous
results later to the infant who does not have the
accumulation of old blood removed, preferably
by operation.® The prognosis of patients with
asphyxial hemorrhage is often bad both as re-
gards life and as regards neuromuscular and
mental development, for the brain damage and
vascular damage are parallel phenomena irre-
parable from birth. Inasmuch as therapy has
very little to offer for this type of patient, pro-
phylaxis would seem to be the only approach.
A consideration of the mechanism of damage
incurred leads to the conclusion that some form
of extra oxygen administration to mothers under-
going prolonged or difficult labor would seem
advisable.

The strikingly frequent occurrence of bleeding
elsewhere in the body at two to five days of age
in infants suffering from intracranial lesions,
especially of the asphyxial t}"pe, has led to the
consideration of a possible causal relationship of
asphyxia to hemorrhagic disease of the newborn.^
While such a relationship has not been definitely
established, the administration by mOuth of
Vitamin K to all infants who have been bom by
difficult or prolonged labor — with even mild

evidence of intracranial damage— would appear
entirely justifiable.

Pulmonary Causes

Pulmonar}^ causes are next in importance to
cerebral causes of cyanosis in the newborn.

Atelectasis — imperfect expansion of the lungs
— is present in all infants during the first two or
three days of life, and for even longer periods
in premature infants. This is, however, a
physiologic atelectasis which becomes of patho-
logic significance only if of unusual severity or
duration, or in the immature infant where weak-
ness of the chest musculature or framework ex-
ists. In very immature infants, there may be
present areas of incompletely developed and con-
sequently inexpansible lung tissue. Inexpansible
areas may also be observed in the luetic infant.

Another serious form of atelectasis is the
socalled secondary or resorption type found in
infants in whom after respiration is established
obstruction in the bronchial tree occurs.
Simple forms of this type may be prevented
by thorough cleansing of the pharynx at birth ;
but a more dangerous variety is seen to de-
velop following intra-uterine asphyxia, with
deep inspiratory effects on the part of the fetus
and aspiration into the smaller bronchioles and
alveoli of amniotic sac contents. This ma-
terial, composed of comified epithelial cells and
vernix caseosa, forms membranous linings to
the alveoli and interferes with exchange of
oxygen and carbon dioxide in the lungs.

Other pulmonary causes of cyanosis are pul-
monary hemorrhage, pneumonia or pulmonary
edema. Pneumonia in the newborn may result
from mouth-to-mouth resuscitation or from other
exposure to infected individuals. Pulmonary
hemorrhage may be part of hemorrhagic disease
or a result of erythroblastosis fetalis, while pul-
monary edema and congestion may follow the
parenteral administration of excessive amounts
of fluids to the newborn. If the lung is well de-
veloped anatomically, a pulmonary hemorrhage
must be large or diffuse, a pulmonary edema
must be extensive, or an atelectasis of con-
siderable degree, usually secondary in type, must
be present for the pulmonary condition to be the
proximal cause in the production of cyanosis.

Congenital defects in the circulatory system

June, 1941

457

PREVENTIVE MEDICINE IN MICHIGAN— KLEINSCHMIDT

or collapse of the peripheral circulation may be
. responsible for cyanosis. Yet it is noteworthy
that infants with severe cardiac anomalies may
go for months or years before cyanosis becomes
a symptom. Better criteria in the neonatal
period for the diagnosis of congenital malforma-
tion of the heart are dyspnea, a persistently high
red cell count, feeding difficulties, congenital de-
fects elsewhere, and cardiac enlargement by
x-ray. Murmurs, like cyanosis, may be absent.

Summary

In newly-born infants, pulmonary causes such
as obstruction of the air passages, atelectasis, or
pneumonia account for many instances of
cyanosis, while congenital defects of the heart
account for a few. The outstanding cause of
cyanosis in the newborn is an intracranial lesion
due usually to intra-uterine asphyxia or to
trauma to the infant’s head during the birth
process. Often both trauma and asphyxia are
operative, inasmuch as asphyxia leads to symp-
toms of fetal distress which cause the obstetrician
to hasten to deliver the infant, thereby inducing
trauma. Asphyxia, characterized pathologically
by engorgement, edema, petechial and in very
severe cases grogs hemorrhages in the brain
tissue, may be caused by certain unavoidable ob-
stetrical conditions, but at times seems definitely
to result from the unwise selection of drugs for
hastening labor or from deep anesthesia to the
mother.

Prognosis in patients with cyanosis of the new-
ly born as a result of trauma depends on the
severity and extent of the cerebral injury and
resultant hemorrhage. Gross hemorrhages in
the subarachnoid space usually have a good
prognosis. Subdural hemorrhages tend to b.e-
come chronic subdural hematomas and often
must be removed by operation. The prognosis of
injury resulting from asphyxia is bad both as
regards life and as regards mental and neuro-
muscular development. It is these patients who
become the cerebral spastics and the mentally
defective children. Prevention of the injury
rather than treatment is necessary in this type
of case.

Bibliography

1. Clifford, S. H. : Hemorrhagic Disease of Newborn; Critical

Consideration. Jour. Pediat., 14:333, (March) 1939.

2. Clifford, S. H., and Irving, F. C. : Analgesia, Anesthesia

and Newborn Infant. Surg., Gynec. and Obst., 65:23, (July)

1937.

3. Cole, W. C. C., Kimball, D. C., and Daniels, L. E. :

458

Factors in Neonatal Asphyxia. Jo<ur. A.M.A.,
113:2038, (Dec. 2) 1939.

4. Eastm^, N. J.: Fetal Blood Studies. 1. The Oxygen Re-
lationships of Umbilical Cord Blood at Birth. Bull Johns
Hopkins Hosp., 47:221, 1930.

5. EastiMn, N. J.: Fetal Blood Studies. 5. The Role of
Anesthesia m the Production of Asph30cia Neonatorum.
Am. Jour. Obst. and Gynec., 31:563, 1936.

6. Ingraham, F. D and Heyl, H. L.: Subdural Hematoma in
1939*’*^^ and C^iildhood. Jour. A.M.A., 112:198, (Jan. 21)

7. Lundsgaard, C., and Van Slyke, D.D.: Cyanosis. Medicine,

8. Smith, C. A. : Effect of Obstetrical Anesthesia upon

Oxygenation of Maternal and Fetal Blood with Particular
^4 ^(?fov )° 1939^°^*^°^^”^’ ^ynec. and Obst., 69:

9. Smith, C. A. : Effect of Nitrous Oxide Oxygen Ether

Anesthesia upon Oxygenation of Maternal and Fetal Blood
at Delivery. Surg., Gynec. and Obst., 70:787, 1940.

Early Beqiimings of Preventive
Medicine in Michigan

By Earl E. Kleinschmidt, M.D.

Chicago, Illinois

Earl E. Kleinschmidt, M.D., Dr.P.H.

B.S., University of Michigan, 1927; MS
University of Michigan, 1928; M.D. Univer-
Mi^^higan, 1930; Dr.P.H.^ University
of Michigan, 1936. Assistant Editor-in-Chief
Journal of School Health; Chairman, Depart-
^ent of Preventive Medicine, Public Health
and Bacteriology, Loyola University School of
Medicine. Member, Michigan State Medical
. Society.

It is the honorable claim of the medical pro-
fession that the great advance in .sanitary knowl-
edge has been brought about mainly by its owm
members.

—David Inglis, M.D., 1886*

During the entire period, 1850-1888, the phy-
sicians of Michigan were always to be found
in the van of the public health movement. “We
claim to be the authors of Preventive IMedicine
Or Hygiene which has, within the past fiftv years,
increased human life 30 per cent,” said Dr.
Geo. E. Ranney of Lansing in his presidential
address before the Michigan Central Medical So-
ciety in 1873.2 Before the establishment of the
State Board of Health, the physicians of the state
were its strongest advocates ; after its creation
they became its staunchest supporters. Matters
of hygiene and sanitation occupied much of their
time at meetings of the district and state medi-
cal society meetings. ^

The State Medical Society

The first state medical society was organized
in accordance with a legislative Act of June 14,
1819. The law thus created provided for the
establishment of a “Medical Society of Michi-
gan,” and also for county societies. Dr. William .1

Jour. M.S.M.S.

PREVENTIVE MEDICINE IN MICHIGAN— KLEINSCHMIDT

Brown was elected its first president.^ Accord-
ing to available accounts this first society received
considerable opposition from the irregular prac-
titioners of the state. In the years which fol-
lowed its establishment, the records indicate that
this antagonism grew in intensity.^

In 1851, the activities of irregular practitioners,
principally herbalists, or Thomsonians, as they
were spoken of, led to the annulment of the Act
of 1819, thus abolishing all legal protection of
medical societies.^ According to Dr. Henry
Taylor of Mt. Clemens, . “the Legislature had
concluded that medical men could get along with
its protection,” thus throwing the medical pro-
fession of the state on its own resources.^ No
effort was made at reorganization until 1853,
when, pursuant to a call by a large number of
physicians in various parts of the state, a meet-
ing was held at the Medical School of the Uni-
versity of Michigan on March 30, 1853, “for
the purpose of organizing a State Medical As-
sociation.”®’®

Following its reorganization in 1853, the Medi-
cal Society of Michigan held annual meetings at
Ann Arbor on commencement day for four
years, the fifth at Detroit, the sixth at Ann Ar-
bor, the seventh at Lansing, and the next at
Coldwater; but so few members were present
that they adjourned once more to Ann Arbor
where the organization again dissolved.® Its
downfall was attributed by Dr. Leartus Connor
to “(1) The commercial disasters of 1857, (2)
the growlings of the approaching civil war,
(3) the natural operation of the feuds of former
years, (4) the lack of stimulus from opposition,
and (5) absence of sustaining interest of many
local societies.”^ The Civil War was shortly to
turn the attention of physicians in the state to
more pressing affairs.

With the close of the war, Michigan physicians
again took steps to organize themselves into a
state society. The district medical society of
Grand Rapids and the North-Eastern District
Medical Association were most active in this
respect.® After conferring with similar organiza-
tions elsewhere in the state, these societies issued
a call for a convention in the city of Detroit on
June 5, 1866.® At the meeting which followed,
about one hundred physicians gathered at the
Supreme Court room from all parts of the
state.® “We have come together now to atone,
as far as in us lies, for the past, and by this re-

union to reorganize and revivify our State
Medical Society,” said Dr. Morse Stewart of
Detroit.® Since that time the society has con-
tinued to grow and extend its usefulness to both
its members and people of the state generally.^®
District medical societies began to be organized
about 1850. The Grand River Medical Associa-
tion was formed at Grand Rapids on the first
Thursday of June, 1851. It included in its mem-
bership, physicians from the counties of Ionia,
Montcalm, Ottowa, Kent and Muskegon.’^^ On
March 8, 1853, a meeting was held at Romeo for
the purpose of organizing another district medi-
cal association.^^ Still another meeting in June
of this same year resulted in the formation of
the South-Eastern Medical Association.^^

As mentioned, the activities of irregular prac-
titioners of medicine and of patent-medicine ven-
dors were the cause of much concern to the
members of the regular medical profession. The
withdrawal, in 1853, of the law sustaining medi-
cal societies of the state enabled the Homeopath,
Hydropathist, Eclectic, Thomsonian, Uriscopic,
and Stick Doctors to raise their heads as high as
the regular physician. This state of affairs, so it
is said, disgusted many medical men.^® “For
more than half a century, have these sticklers
for equal rights — these advocates for. unbridled
liberty, been making their appeals to community
to enkindle a prejudice,” said Dr. Henry Taylor
of Mt. Clemens, “and create disapprobation of the
medical profession — accusing them of monopoliz-
ing the healing art, however pleasing or profit-
able they might think to make it to themselves,
and thus withhold from them the pleasure of
contending arm to arm, and on equal ground,
with death, and of wrestling with the diseases
and suffering of their fellow-men.”^® The news-
papers of this period (1850-1888) were filled
with the advertisements of patent medicine ven-
dors and of numerous kinds of quacks.^®

In his presidential address of 1871, Dr. I.
H. Bartholomew devoted a considerable por-
tion of this address to the subject of quackery
in the state.^^ “The public in its zeal to over-
throw exclusive rights (those of the profession
among others),” said Dr. Bartholomew, “and
to give evidence of the propriety and sincerity
of its course, made it legal for idiots to prac-
tice medicine, and then offered itself, a great
conglomerate patient, for idiots to practice

June, 1941

459

PREVENTIVE MEDICINE IN MICHIGAN— KLEINSCHM IDT

on.” To secure a following among the peo-
ple, quacks and charlatans made frequent use
of the mails, sending out circulars which
claimed to simplify the true science of medi-
cine.^'^ Large numbers of quacks, so it is said,
came to Michigan in 1881 following the enact-
ment of a law in Illinois regulating medical
practice and depriving them of a livelihood.^®

Among the more vociferous of the irregular
practitioners of medicine in the state were the
group known as "Homeopaths.” With the ap-
pearance of the Michigan Journal of Homeopathy
in December, 1848, repeated diatribes were di-
rected against their competitors, the regular phy-
sicians, whom they chose to call "Allopaths.
The editors of this journal, Drs, John Ellis and
S. B. Thayer, openly avowed their intention of
overthrowing the system of medical practice used
by their medical brethren. "We here freely state
what we desire to see accomplished,” wrote Drs.
Ellis and Thayer in their initial number of the
Journal, "it is nothing less than an entire over-
throw of the present system of bleeding, blister-
ing, vomiting, physicking, salivating, et cetera,
and the substitution of Homeopathy, a system as
beautiful and harmless, as it is scientific and
efficacious ;• and we shall never be satisfied until
the old practice in all its forms is entirely over-
thrown, and the new universally substituted.”^^
"In presenting a medical Journal to the public.”
they asserted, “it is but reasonable that we state
why we are induced to it, what we desire to ac-
complish, and whether we can hold forth to our
patrons a reasonable prospect of success. No
one can question for a moment the importance
of medical men possessing correct medical knowl-
edge, but why, we ask, should the community
be kept in ignorance on medical subjects? Is
the preservation of health and life of no im-
portance, and is knowledge upon this subject of
no use to the community? We believe it is of
vast importance, and that true knowledge tends
to elevate the minds of those who receive it ;
and, as the mind becomes elevated into the free-
dom of truth, the individual feels within him a
strong desire to impart the knowledge he pos-
sesses, and to elevate all around him to his own
standard, unless he bows down a willing slave
to his own selfishness, or cultivates a pride of
opinion as unjust to his fellow-men, as it is con-
temptible. Who but the quack, desires exclusive

privileges, carries a knowing look, shrouds medi-
cal subjects in mystei*}', strenuously withholds
from his patients and the public all knowledge
of composition of his medicines and compounds,
encourages the use of patent-medicines, strives
to obtain penal enactments and laws, to protect
him in the enjoyment of his ill-gotten popularity’?
The quack, fearful that the public will not ac-
knowledge his worth, and conscious of a lack of
knowledge, of arguments and of skill, appeals
to the above to sustain his influence instead of
appealing to the understanding of his fellow
men. Believing that the great truths of Homeop-
athy, and the advantages resulting from their
adoption are so manifest that they can be com-
prehended by an intelligent people, and believing
that this community possesses the requisite intelli-
gence, we have established this Journal for the
purpose of proclaiming these truths, and likewise
of spreading light and knowledge on medical
subjects generally.”^’^ The first seven numbers
of the Journal contained a series of articles en-
titled "What is Homeopathy?”

Prevention of disease was strongly advocated
by Messrs. Ellis and Thayer. "As the preven-
tion of disease is quite as important as its cure,”
they said, "and as it has been almost entirely
neglected by medical men, we shall, as we have
opportunity, call attention to the diet suitable for
well and sick, to the great abuse of medical sub-
stances in food and drink, as well as pass in
review the different methods of drugging, which
are so prevalent, not only in, but out of the
profession, from which arise such a multitude
of drug diseases.” "Strange as it may appear,”
they added, “the most beautiful feature of this
system, the smallness of the dose, is the point
which meets with the strongest and most unre-
lenting opposition. So long have physicians and
even patients, yes, even children, been accustomed
to associate suffering and torture with the idea
of being cured of disease, that the possibility of
being relieved without being made sick is re-
garded as absurd by medical men, while patients
expect to run the gauntlet between diseases and
the doctor, and do not expect to be cured with-
out being made worse, and submitting to the
most cruel and unnatural operations, such as the
lancet, cathartics, blisters, et cetera, et cetera,
which, of themselves, are sure to make even
well men sick. Even children learn to look upon
the physician as a regular leech, and fly at his

460

Jour. M.S.M.S.

PREVENTIVE MEDICINE IN MICHIGAN— KLEINSCHMIDT

approach as such, while parents hold the doctor
over them as a rod of correction. ]\Iay we not
then look for a radical change, a change which
shall not suffer more than one half of the inhab-
itants of the world to die before they are ten
years old, as they do under the present practice ?
Take from homeopathy her infinitesimal doses,
and she is shorn of her beaut}’, and, to a great
extent, of her efficacy, and becomes even less
safe than allopathy.”^"

In 1875, the legislature was so influenced by
the entreaties of the homeopathic practitioners
of the state that they passed an act authorizing
the Board of Regents of the University of
^Michigan to establish a Homeopathic Medical
College as a branch of the Universit}’, to be
located at Ann Arbord® This occurrence pro-
voked still greater rivalr}’ between the adherents
of the two systems of medical practice.^® The
medical literature of this period is filled with
accusations and counter-accusations of the fol-
lowers of both groups. “The \ery nature of the
purposes of the Board,” said Dr. H. O. Hitch-
cock, referring to the activities of the State
Board of Health, “left it out of and above the
field of the active, constant, and many-sided strife
of the pathies, because, as a board of health, it
does not concern itself with the practice of medi-
cine, or with the theoretical or practical action
of remedies on the various diseases. Hence it
can, does, and ought to cooperate with, and re-
ceive the cooperation of all individual members,
and all organized societies of the profession in
its means and measures for the prevention of
disease.” In spite of this expression of unbiased
adherence to either system of medicine, both the
State Board of Health as well as the State Medi-
cal Society took an active part in seeking to
improve the quality of medical practitioners and
medical education in the state.

State Board of Registration

The original effort in 1819 to regulate the
practice of medicine by the enactment of pro-
tective legislation, resulted in dismal failure.^®
Outcries by quacks and irregular practitioners
in the state for “equal opportunities” were to
lead to the abolition of all protective medical
legislation in 1851.^° In the years which fol-
lowed, however, other developments occurred
which were destined to be far superior to legal
protection of organized medicine.

At the fourth annual meeting of the State
Medical Society on June 8, 1870, Dr. H. O.
Hitchcock of Kalamazoo introduced the follow-
ing resolution ;

Resolx'ed, That the society will hereafter annualh' se-
lect two members each, to visit the medical schools of
the State, and especially attend the examination of can-
didates for the degree of Doctor of Medicine and faith-
fully to report to this Society upon the conditions of
the schools and the thoroughness of their teachings and
examinations.

The resolution was adopted by a tmanimous
vote.^° The following year at a similar meeting,
still another resolution of the same nature was
adopted."^. Dr. William Parmenter of the Com-
mittee on Legislation urged that a law be passed
requiring competent qualifications of all who
would practice medicine.

Soon after the State Board of Health was es-
tablished, it was evident to several of its members
that the Board must take an active part in the
issue if it was to live up to the objectives set
for it. Evidently influenced by a law passed at
the session of the Illinois Legislature in 1881,
Dr. Hitchcock offered the following resolution
which was adopted :

Resol\’ed, That the committee on legislation be re-
quested to make inquiries to the recent Act in the
Illinois Legislature “Regulating Medical Practice,” and
to its practical working, and to report to this Board
whether in its opinion a similar Act in our own state

is desirable. 23

Another resolution offered by Dr. Henry F.
Lyster at this same meeting was amended to read
as follows :

Resol\^d, That this Board organize itself into an
examining college, and institute an annual examination
of candidates in subjects relating to public health.

This latter resolution was referred to a special
committee, consisting of Dr. Lyster and the
Hon. LeRoy Parker, to be reported on at the
next meeting.^^

The following year the Hon. LeRoy Parker,
Committee on Legislation, reported that in his
opinion a similar law for the State of ^Michigan
was desirable, but he doubted very much that
the State Board of Health should be the bod}'’
authorized to conduct such examinations or issue
certificates. Lack of personnel, financial remu-
neration, and possible conflict with schools of
medicine were cited as reasons why the Board
should refrain from engaging in this practice.-'^

JuxE, 1941

461

PREVENTIVE MEDICINE IN MICHIGAN— KLEINSCHMIDT

He, however, concurred in the proposal of Dr.
Lyster of the Board, that the State Board of
Health conduct examinations which were to be
voluntary.^^ Later in the same meeting, a pre-
amble and memorial were drawn up by Dr. Hitch-
cock, which petitioned the legislature to enact
some law or laws for the protection of the
people from the dangers to life and health at-
tendant upon the medical practice of ignorant
and unqualified practitioners of medicine. This
was adopted with one amendment, and signed
by members of the Board and next transmitted
to the legislature.^® It passed both branches of
the tegislature, but for reasons not revealed in
available reports, it failed to receive the signature
of the Governor owing to some technicality in
its passage.^®

On October 10, 1880, the following resolution
was offered by Dr. Henry F. Lyster at a meeting
of the State Board of Health :

Resolved, That a committee of three be appointed by
the chair to report at the next meeting upon a plan
for the legalization and registration of the medical pro-
fession in this State, and to confer with such other
organizations or individuals as may be interested in the
passage of a bill regulating the practice of medicine by
the Legislature of Michigan.^

This was concurred in by those in attendance
at the meeting, and a committee consisting of
Dr. Henry B. Baker, Dr. Henry F. Lyster, and
Rev. D. C. Jacokes appointed to study the resolu-
tion. According to the accounts which follow,
nothing apparently was done, for on October 10,
1882, at another meeting of the Board, the Hon.
LeRoy Parker and Rev. D. C. Jacokes were ap-
pointed a committee on the practice of medicine
in place of the former committee which was or-
dered discharged.^® On January 9, 1883, the
following resolution was adopted by the Board :

Resolved, That there should be required of all who
are to begin the practice of medicine in this State an
examination as to their qualifications.

Resolved, That such examinations by the State should
be restricted to questions in demonstrable knowledge
as distinguished from questions of mere opinion.

Resolved, That as a public health measure these two
resolutions be referred to the president and secretary
with a request that they do what they can to promote
the objects of the resolutions.^

Dr. Baker went a step further and drew up
a proposed bill to regulate the practice of medi-
cine in the state. This he had published in the
Michigan Medical News.^'^ Apparently these sev-
eral efforts were unavailing, for a search of the

literature in the period under consideration
(1850-1888) fails to show further progress in
this direction.

Efforts to secure registration of physicians in
the state were more successful. The Hon. Le-
Roy Parker, Committee on Legislation of the
State Board of Health, succeeded in getting a
bill for this purpose before the legislature where
it was favorably received and passed late in
1883.

This act (No. 167, Laws of 1883) required
all practitioners of medicine and surgery or
any other branch thereof to file with the clerk
of the county in which they engaged in prac-
tice, or in which they intended to practice, a
sworn statement setting forth the length of
time they had engaged in continuous prac-
tice in said county, and if a graduate of a
medical school, the name of the same and
where located, when they graduated, and the
length of time they attended school; also the
school of medicine to which they adhered.
County clerks were required by the act to
record these statements in a book.^®

A similar law (Act No. 140, Laws of 1883)
required all dentists in the state to register in a
like manner with the county clerk in their locali-
ty.^® In January, 1884, Dr. Baker of the State
Board of Health, sent a circular, together with
a blank form, for reply to all the county clerks
of the state, asking them for the names, ad-
dresses, et cetera, of the physicians in the state.^®
According to the replies received, “the number
of practitioners returned is 3,270, of whom 2,366
or 72 per cent, are reported to have graduated
from some college, society, or institution; 197,
or 6 per cent, are reported to have attended some
college ; and 707, or 22 per cent, are not reported
to have attended a college or anything that could
be called a medical school.”®®

In 1887, the original act was slightly amended
(Act No. 268, Laws of 1887) to permit clerks
of cities, villages, and townships to transmit to
the Secretary of the State Board of Health a
list of medical practitioners in their jurisdiction.®®

Interest in Sanitation and Hygiene

From evidence already cited, it is clear that
medical societies played a major role in further-
ing the progress of the public health movement.

462

Jour. M.S.^I.S.

PREVENTIVE MEDICINE IN MICHIGAN— KLEINSCHMIDT

As a professional group they gave freely of their
time and worked unselfishly in the promotion of
community welfare.* Many of the ideas which
later culminated in the Registration Law of 1867,
and still later in the establishment of the State
Board of Health, had their birth in the papers
read before district and state medical societies.

At the seventh annual meeting of the State
Medical Society, a resolution was introduced by
Dr. Pratt of Kalamazoo requesting the legislature
to print the annual transactions of the State IMed-
ical Society as a State Document:

Whereas, The transactions of this Medical Society
must contain much information relative to the preser-
vation of health and the prevention of disease, which
it will be important to the people of this State to have
in possession; and

Whereas, It is unjust to require the Medical Pro-
fession, at their individual expense, to publish this in-
formation for the benefit of the State; and

Whereas, Other Legislatures have recognized it as
their duty to spread before the people they represent
all facts having an important bearing upon sanitary
reform; therefore, be it

Resolved, That we respectfully request the Legislature
of this State, now in session, to inaugurate the practice
of publishing as one of the State Joint Documents, the
Annual Transactions of this Society

This resolution was adopted by a unanimous
vote and laid before the legislature by a com-
mittee from the State Medical Society.®” There
it was favorably acted upon by both branches of
the legislature and approved by the governor.
As far as the records reveal, this is the first in-
stance in which the State Legislature ordered a

*At the seventh annual meeting of the State Medical Society,
Dr. H. B. Baker offered the following resolution which was
adopted by the Society:

Resolved, That while the physician’s work of relieving human
suffering is one of the noblest of human employments, it is more
honorable to the profession, and very much more to the interest
of the people, when physicians are paid for and employed as
much as possible in preventing sickness, than when entirely em-
ployed in combatting results or causes, many of which might
be removed or avoided by the use of means within the present
knowledge of physicians; that this society therefore, earnestly
recommends and encourages the employment of physicians:
First, as health ofhcers on boards of health; Second, as lec-
turers and instructors in hygiene in the public schools; Third,
as sanitary advisors of government officers, of corporations, per-
sons, or families, on special occas'on, or by the year; Fourth,
as editors of sanitary journals or publications or in any other
honorable manner whereby it becomes equally for the interest
of the physician and the people that health prevail.

Resolved, That this society warmly approves of the action
of the late and of the present Governor of this State, in recom-
mending the establishment of a State Board of Health, and of
the Le^slature, in passing a law providing for the same;
that it is reasonable to hope that much good will result from
the intelligent action of such board in their labors for the
prevention of unnecessary deaths and disease among the people
of this -State.

Resolved, That in view of the prospective demands upon
physicians for the application of sanitary science to the affairs
of government and of society, it becomes important that medical
colleges give increased attention to teaching those who are
to be physicians concerning the cause and methods of preventing
dise.ses, and that in future individual members of our pro-
fe^ion endeavor to contribute liberally to the advance of the
science of public hygiene, in order that the profession may
continue to maintain its leading position in advance of the de-
mands of the people. — Trans. M.S.M.S., p. 18, 1873.

document published because of its value in im-
proving the public health.®^, For some reason
which the records fail to reveal, the practice of
publishing the transactions of the State Medical
Society by the state was not resumed after the
Civil War.

At the initial meeting for organization of the
State Medical Society at Detroit in 1866, a
committee on “Medical Hygiene” was appointed,
consisting of Drs. A. B. Palmer of Ann Arbor;
D. O. Farrand of Detroit, and C. Paddacke of
Pontiac.®® This appointment was made at the
suggestion of Dr. J. H. Jerome of Saginaw City.®®
Elsewhere in the state, other committees on hy-
giene were shortly to lend impetus to the public
health movement.®^

Physicians and the State Board of Health

In general, the physicians of the state con-
tinued their interest in hygienic matters long
after the State Board of Health was established.
Cooperation with the Board, however, was fre-
quently asked by those who saw the need for co-
operative action by the physicians of the state
with the local and state boards of health. An
editorial appearing in the Detroit Review of
Medicine and Pharmacy, soon after the State
Board of Health was established, urged the phy-
sicians of the State to follow its leadership:

Michigan State Board of Health

It is well known to all our readers that we have a
State Board of Health, one well qualified for its work.
This board has chosen for its secretary. Dr. H. B.
Baker, Superintendent of Vital Statistics. His ability
and fitness for his task are superior in every respect.
Thus, with a competent board and competent secretary,
we shall look for great and good results to the pro-
fession and people of the State.

No study of the health of Michigan will be entirely
satisfactory until it is able to combine the individual
study of each active physician in every city, t03vn, ham-
let, and even open country. What the signal service
has been in relation to the climate of our country, is a
feeble type of what our board of health may expect to
be in relation to public health, if fully supported by
every physician. Let us, brethren, organize under
their direction, and labor without ceasing for the ac-
complishment of this great end. It will make demands
upon our ease, our time, our pockets, our brains, etc,,
but let us give as needed, without stint, without a
murmur, cheerfully, earnestly and conscientiously.^

During the same year at a meeting of the
State Medical Society, Dr. Foster Pratt of Kala-
mazoo offered a resolution calling for the support
of the State Board of Health by the State Medi-
cal Society. This was heartily approved.®®

June, 1941

463

PREVENTIVE MEDICINE IN MICHIGAN— KLEINSCHMIDT

Other members of the State Medical Society,
however, were inclined at times to disagree with
their colleagues relative to the policies of the
State Board of Health. This is readily apparent
from remarks made by Dr. William Brodie in
his presidential address in 1876 before the tenth
annual meeting of the State Medical Society.
Said Dr. Brodie, “The subject of Hygiene is one
of important interest, not only to the physician
but to the citizen. The laws of health cannot
well be disregarded without entailing their con-
sequences. Heretofore this subject has occupied
the attention of the different medical societies.
State and local, but since the advent of the State
Board of Health this interest has in a measure
abated, owing to the fact that the Board of
Health has taken it under its own special pro-
tection. It is evident from an examination of
the reports of the Board that the profession out-
side thereof take but little interest in its labors
and furnish but a small modicum of their pro-
ceedings. This can be accounted for on two
grounds at least, which are fundamental to its
success ; ( 1 ) The Board is composite, having
professional and non-professional elements in its
formation, when it should be entirely medical.
(2) Although the law of its organization says
nothing about its political complexion, yet all
the members have been of the same political
creed as the Governor while men of medical
and scientific attainments, without equal, if not
of more experience, but holding contrary politi-
cal opinions, have not been thought worthy of ap-
pointment. Science should know no political be-
lief, but when it is so prominently thrust forward,
as in the organization of the State Board of
Health, it presents sufficient reasons for the
lack of interest on the part of many of the
profession. Yet another reason may be added.
By the law, instead of each township, village,
or city having a well-informed physician prop-
erly compensated, and as such properly recog-
nized by law, to examine into the hygienic con-
ditions of the locality under his jurisdiction and
report to the Board the whole subject is
left to be examined and reported upon
by the clerk of such township, village or
city board of health, whose education might
be so limited on the subject as not to know
whether excessive moisture or excessive dryness
is most productive of malaria. Notwithstanding
all this and the consequent inaccuracies of statis-

tics collated under such circumstances, the Board
has presented a large amount of practical infor-
mation, which has been distributed to the public
through their annual reports prepared by their
efficient Secretary, a member of this Society, Dr.
Henry B. Baker. For reasons which the rec-
ords fail to explain, he also recommended, in the
course of his address, that a committee of one
physician from each organized county in the
state be appointed to report upon its hygienic
condition at the next annual meeting.^

In 1880, Dr. H. O. Hitchcock, a member of
the- State Board of Health, offered a resolution to
the State Medical Society — “Resolved, That in
the opinion of the members of this Society the
laws of the State requiring physicians to report
to the local board of health, or to the health officer
of their locality, all cases of sickness and death
of disease contagious or dangerous to the public
health, are wise and proper and ought to be com-
plied with.”®® To this Dr. Brodie and several
others took strong exception, asserting that the
state had no right to compel the ser\dces of phy-
sicians in such duties without remuneration. On
motion, however, the resolution offered by Dr.
Hitchcock was approved.®®

State Medical Journals

The several medical journals published at vari-
ous times during the period under consideration
(1850-1858) contributed in many ways to the
growth of the public health movement. The
Michigan Journal of Homeopathy, although ex-
pounding chiefly the theory of Hahnemann, de-
serves mention in that it endeavored to educate
the people in matters of health and disease. This
journal was begun on November 11, 1848, by
Drs. John Ellis and A. B. Thayer of Detroit and
continued until June, 1854.®^ The Peninsular
Journal of Medicine and Collateral Sciences had
its beginning in 1853.^° This was the chief organ
of the regular profession. It devoted consider-
able space to observations on meteorolog}’ and the
health of the people in the state.®® “This enter-
prise,” said Dr. E. Andrews, its editor, “has long
been contemplated by the profession of Michigan,
and the want of it has been severely felt. What
the medical men of this region need is to con-
centrate their power, and organize their strength.
There is intellect enough, and learning enough

464

louR. M.S.M.S.

PREVENTIVE MEDICINE IN MICHIGAN— KLEINSCHMIDT

among them to command the highest honor and
respect' from community and there is power
enough to blow the breath of annihilation upon
their enemies, and sweep out quackery as in a
whirlwind from their path.'*” According to Dr.
Walter H. Sawyer of Hillsdale, writing in the
Medical History of Michigan, “The Journal or-
ganized movements which finally resulted in the
proper care of the insane in institutions under and
conducted by the State instead of by counties,
movements for the proper registration of deaths,
births, and marriages ; for state and local health
boards.”®” This journal merged with another
similar publication in 1858 becoming the Penin-
sular and Independent Medical Journal. As such
it continued until March, 1860, when it was dis-
continued because of lack of funds.** Following
the war period, another journal made its appear-
ance having the title of Peninsular Journal of
Medicine. Other journals of this period included
the Detroit Lancet, the Michigan Medical News,
and the Detroit Review of Medicine and Phar-
macy.

References

1. Trans. 6:272, 1886.

2. Trans, M.S.M.S., 2:6, 1873.

3. Trans. M.S.M.S., 1:5, 1870.

4. Pen. Jour. Med., 1:388, 1854.

5. Trans. M.S.M.S., 1:5, 1870.

6. Pen. Jour. Med., 1:48, 1853.

7. Pen. and Ind. Med. Jour., 2:682, 1860.

8. Det. Rev. Med. and Pharm., 1:86, 139, 1866.

9. Trans. M.S.M.S., 1:17, 18, 1867 and 1868.

10. Trans. M.S.M.S., 3:12, 1870.

11. Pen. Jour. Med., 1:100', 233, 466, 1853.

12. Pen. Jour. Med., 1:388, 389, 1854.

13. Detroit Advert, and Tribune, 29:8, June 9, 1865.

14. Trans. M.S.M.S., 5:8, 11. 1871.

15. Trans. M.S.M.S., 6:66, 1872.

16. Annual Report State Board of Health, 10':92, 1883.

17. Mich. Jour. Homeopathy, 1:1, 3, 77, 1848.

18. Trans. M.S.M.S., 6:423, 1876.

19. Trans. M.S.M.S., 3:530, 1873.

20. Trans. M.S.M.S., 1:4, 5, 16, 1870.

21. Trans. M.S.M.S., 2:19, 1871.

22. Trans. M.S.M.S., 3:91. 1872.

23. Annual Report State Board of Health, 7 :xlv, xlvi, 1880.

24. Annual Report State Board of Health, 7 :49, 50, 1880.

25. Annual Report State Board of Health, 9:xxxiv, 1882.

26. Annual Report State Board of Health, ll:xxxii, xxxiii, 1884.

27. Mich. Med. Ne'ws, 5:296, 1882.

28. Annual Report State Board of Health, 12:115, 116, 119,
1885.

29. Annual Report State Board of Health, 16 :x, 1889.

30. Pen. and Ind. Med. Jour., 1:703, 1859.

31. Annual Report M.S.M.S., l:State Document No. 15, 1859.

32. Det. Rev. Med. and Pharm., 1:191, 1866.

33. Trans. M.S.M.S., 1:20, 1867 and 1868.

34. Det. Rev. Med. and Pharm., 1:210, 1866.

35. Det. Rev. Med. and Pharm., 8:521, 1873.

36. Trans. M.S.M.S., 4:17. 1873.

37. Trans. M.S.M.S., 5:421, 1876.

38. Trans. M.S.M.S., 7:490, 533, 1880.

39. Medical History of Michigan, 1:629, 630, 1930.

40. Pen. Jour. Med., 1:47, 1853.

41. Pen. and Ind. Med. Jour., 2:768, 1880.

YOU WILL NEVER . . .

You will never operate under a carbolic acid shower. You will probably never carry a
catheter in the sweatband of your hat. You will never see tan bark on the streets around
hospitals to prevent noise or bales of oakum and peat moss in hospital corridors to be used
as overdressing for infected wounds. You will never see 100 cases of typhoid in a row or
5 in one family die of diphtheria in one and one-half hours !

At the one hundred and thirty-fifth annual meeting of the Medical Society of the State
of New York, 1941, in Buffalo, you will see not a single tracheotomy demonstrated or 1
case of diphtheria intubated. Yet at the time of the eighty-first meeting, O’Dwyer’s tubes
were the surgeon’s hope. Of his experiences Jacobi wrote: “nearly 3,000 tracheotomies,
2,800 terminated in death.” Fifty-four years.

You might come to Buffalo on April 28 by steam train or arrive in a horse-drawn
buggy, if you live close by, as you would have come to the eighty-first meeting; but the
chances are you will come by automobile or plane this year, if you can, and keep in touch
with your office by using the improved facilities of Mr. Bell’s recently developed telephone.
If you are unavoidably prevented from attending, you may be able to hear some of the
proceedings through the courtesy of Senatore Marconi, Dr. Lee DeForest, and others of
our recent co-workers in science. And we can assure you that they will be worth hearing.

We think it only fair to remind members that while in Buffalo they will be within the
jurisdiction of the hardy and formidable Medical Society of the County of Erie. In the
year 1827 the society’s receipts in membership fees amounted to $11. A resolution au-
thorized the treasurer “to collect outstanding dues from members — peaceably if he can,
forcibly if he must.” Such is the quality of our hosts. Surely the visiting membership of
the State Society can reasonably expect great things from men of such caliber, vigor, and
determination.

In passing, it is of more than historic interest that in the University of Buffalo, founded
in 1846, Dr. White raised a storm of protest in Buffalo, throughout the state, and, indeed,
throughout the United States by “introducing demonstrative or clinical midwifery” into
the college course. It had never before been attempted in this country. “Seldom,” it is
said, “has an event occurred that so completely shook the foundations of society in any
city as did this.” Newspapers denounced it as immoral. Dr. White was drawn into the
law courts and was vindicated ; for many years he continued to teach obstetrics and
gynecology in the university.

Noteworthy also is the fact that Dr. Roswell Park and Assemblyman Henry W. Hill se-
cured in 1898 from the Legislature the first appropriation ever made from public funds,
either in this country or abroad, for the purpose of combating the ravages of cancer.

Currently, we are immersed in vast preparations for national defense. These preparations
contemplate not only the mobilization of large numbers of men but the mobilization also
of the vast store of technical and scientific knowledge which is available. Much of this
will be forthcoming at the annual meeting for your benefit. Make it your business to be
there.

JuNi:. 1941

465

-X EDITORIAL x-

MAD DOGS

■ Every now and then a book of fiction is pub-
lished in which the theme of the story deals
with an evil person who sets loose mad, vicious
dogs to protect him from his enemies so that he
might pursue his malicious ways.

Today we are living through such a period.
Not alone in Europe, Africa and Asia have the
mad dogs of war been loosened but also the mad
dogs of economic and social existence have been
released from their necessary restraint in the
United States to make more rapid a sure, but
slowly progressing change.

It has even permeated the field of health.
Idealists have been given free reign and among
them those whose main attributes are instability
and lack of respect for sane evolution. It has
been said that ideals are dangerous explosives, to
be entrusted only to experienced hands.

In the Wisconsin legislature the American
Medical Association was accused of having re-
fused to take cognizance of the fact that large
groups of our population are deeply concerned
on the subject of how they can beat the high
cost of medical care. “* * * But these people
are being thwarted in their efforts in one little
simple device on the part of the A.M.A and its
constituent societies * * * !” This “device” re-
ferred to is evidently the action of hospital staffs
in refusing membership to unethical doctors of
medicine.

Sympathy with the desire to provide all people
with the best physical care and comforts is of-
fered generally. In the hands of some politicians
and idealists this means the revolutionary de-
struction of great principles ; those great princi-
ples, by adherence to which hundreds of thou-
sands of men sacrificed the indulgence of their
mental and physical welfare in order that a
greater share of these benefits may be reserved
for the unfortunate.

Strive as one may to find more sincere aims,
the only connecting link in the entire chain of
facts is an endeavor to enslave the medical
profession. When that day comes the physician
must be in politics for his livelihood. Now, the
physician needs to be in politics to destroy these

4h6

mad dogs and restrain and restrict the idealist,
as one punishes an irresponsible child — not pro-
hibit free exercise, but keep it within the bounds
of sanity until security and realization of re-
sponsibility make safe their untrammeled free-
dom.

Benjamin Franklin once said, “They that can
give up essential liberties to obtain a little tem-
porary safety deserv'e neither liberty nor safety.”

THE DOCTOR AND SAFETY

■ There is probably no other profession or

group which has as intimate interest in the
safety problems of the people as the doctors of
medicine. It is, moreover, probably the only
group which preaches, fights and acts for pre-
vention when the continuance would increase
financial gain,

[Were we of the medical profession as sordid
commercialists as has been declared, the practice
of medicine would be a sorry one, indeed.]

Most physicians, however, feel that their or-
ganizations are still not using all the influence
possible in this angle of preventive medicine.
While the means for securing these preventive
measures are not as peculiarly medical in charac-
ter as those advocated for the control of epidem-
ics, the organized profession does and should,
in a continuously increasing amount, urge the
adoption of rules, procedures, and construction,
along with education, for the prevention of acci-
dents as well as disease.

1. American Medicine, under the system of inde-
pendent practice and self-discipline and control, has
developed and provided the most effective and most
widely distributed medical service ever known in the
world.

2. There is no panacea for the general problem of
providing medical care — the need varies according to
conditions and types of populations.

3. There is a well defined and powerful group which
seeks to remove the control of medical service from
physicians and place it in the hands of political groups
regardless of the quality and effectiveness of the serv-
ice to the public.

4. The first and most essential requirement in pro-
viding adequate medical care is an understanding, on
the part of the public, of the constituent elements of a
satisfactory service. — Natioml Physicmis Committee
for the Extension of Medical Service.

Tour. M.S.M.S.

Success, and Thanks

A MOST successful legislative experience has been
the fortunate lot of the medical profession this
year. A number of good health and medical bills have
been enacted into law; those proposals inimical to the
health of the people have quietly been killed by the
Legislature.

Thanks, most sincere, are extended to the members
and officers of the Legislature, and to the Governor,
for the courteous reception extended the representa-
tives of the medical profession and the thoughtful con-
sideration they have given medical and health meas-
ures coming before them.

Grateful acknowledgment, and a sincere vote of
thanks, is extended to the three hundred legislative
“key-men” of the Michigan State Medical Society, for
their sacrifice of time, effort and expense in contacting
members of the Legislature and keeping them in-
formed concerning the highly technical medical legis-
lation— exactly fifty-one proposals — which were be-
fore the Legislature in 1941. The work of these fam-
ily physicians and friends of the legislators has been
a constant task from the time the Legislature con-
vened on January first until it adjourned at the end of
May.

Again, Your Excellency, Honorable Members of
the Legislature, and members of the Michigan State
Medical Society, we thank you !

44

President, Michigan State Medical Society

a^e

44

June, 1941 -

467

>f YOU AND YOUR BUSINESS ^

THE BROWN-WAGNER-GEORGE
HOSPITAL CONSTRUCTION BILL

Senator Brown of Michigan recently intro-
duced into the United States Congress S-1230
for himself, for Senator Wagner of New York
and Senator George of Georgia.

The purpose of Senate Bill 1230 is to offer
grants-in-aid to assist state and other political
subdivisions in constructing, improving and en-
larging needed hospitals especially in rural
communities and economically depressed areas,
and to assist in the maintenance of such hos-
pitals and in the training of personnel.

This bill is identical with the Wagner-George
Hospital Construction Bill (S-3230), which was
passed by the Senate (but not by the House of
Representatives) in the 76th Congress.

The present bill retains the provision for os-
teopathic representation on the National Advis-
ory Hospital Council to be created by the bill.

Calling All Doctors

who hove taken postgraduate work other
than in our Michigan program.

Please send details for evaluation and
credit at once to the State Secretary,
L. Ferncdd Foster, M.D., 919 Washington
Avenue, Bay City.

It also retains the broad definition of the term
“hospital” which would include “health, diag-
nostic and treatment centers, the equipment
thereof and facilities relating thereto” The po-
tentialities wrapped up in this definition need
not be emphasized!

The impact that such a building program i
would have on the practice of medicine in Mich-
igan, as well as in the United States generally,
can easily be visualized! )

DAMAGE MUST RESULT FROM THE ACT

Before recovery may be had against a phy-
sician or surgeon for an alleged tortious act it
must first be proved that the damage alleged
came from the act complained' of. Anyone may
be guilty of every conceivable kind of negli-
gence, but if no damage results from it no legal
action can be predicated upon it. — Humphreys
Springstun, of the Detroit Bar. Doctors and
Juries. P. Blakiston’s San and Co., Inc., 1935.

468

Jour. M.S.M.S.

OUTLINE OF GENERAL ASSEMBLY PROGRAM
Seventy-sixth Annual Meeting, Michigan State Medical Society
Grand Rapids — September 17, 18, 19, 1941

Wednesday, September 17

Thursday, September 18

Friday, September 19

A. M.
9:30 to
10:00

Medicine

Russell L. Cecil, M.D.
New York City

Obstetrics (Maternal Health)
James R. McCord, M.D.
Atlanta, Georgia

ON THE

SEVEN SECTION PROGRAMS

General Medicine
A. R. Barnes, M.D.
Rochester, Minn

Surgery

Harry E. Mock, M.D.
Chicago

Obstetrics & Gynecology
Richard TeLinde, M.D.
Baltimore

Ophthalmolog^y & Otolaryngology
Samuel Iglauer, M.D.
Cincinnati

Pediatrics

Harold K. Faber, M.D.

San Francisco

Dermatology & Syphilology
S. Wm. Becker, M.D.
Chicago

Radiology, Pathology, Anesthesia
Bernard H. Nichols, M.D.
Cleveland

10:00 to
10:30

Surgery

Elliott C. Cutler, M.D.
Boston

Medicine (Tuberculosis)
Charles E. Lyght, M.D.
Northfield, Minn.

10:30' to
11:00

VIEW EXHIBITS

VIEW EXHIBITS

11:00 to
11:30

Syphilology

Francis E. Senear, M.D.
Chicago

Medicine

V. P. Sydenstricker, M.D.
Augusta, Georgia

11:30 to
12:00

Gynecology

George W. Kosmak, M.D.
New York City

Pediatrics

James Gamble, M.D.
Boston

P. M.
12:00 to
12:30

Medicine (Mental Hygiene)
Lawrence Kolb, M.D.
Washington, D. C.

Obstetrics

Wm. E. Caldwell, M.D.
New York City

12:30 to
1:30

LUNCHEON
VIEW EXHIBITS

LUNCHEON
VIEW EXHIBITS

LUNCHEON
VIEW EXHIBITS

1:30 to
2:00

Anesthesia

Wesley Bourne, M.D.
Montreal

Ophthalmology
Alfred Cowan, M.D.
Philadelphia

Otolaryngology

D. E. Staunton Wishart, M.D.
Toronto

2:00 to
2:30

Surgery (Indus. Health)
A. J. Lanza, M.D.
New York City

Pathology

Shields Warren, M.D.
Boston

Dermatology

Carroll S. Wright, M.D,
Philadelphia

2:30 to
3:00

VIEW EXHIBITS

VIEW EXHIBITS

VIEW EXHIBITS

3:00 to
3:30

Pediatrics

Henry Poncher, M.D.
Chicago

Medicine

Chester S. Keefer, M.D.
Boston

Pediatrics (Child Welfare)
E. C. Mitchell, M.D,
Memphis

3:30 to
4:30

DISCUSSION
CONFERENCES
WITH GUEST
ESSAYISTS

DISCUSSION
CONFERENCES
WITH GUEST
ESSAYISTS

3:00 to 4:00
Medicine

C. A. Doan, M.D.
Columbus

4:00 to 4:30
Surgery

Owen H. Wangensteen, M.D,
Minneapolis

8:30 to
10:00

President’s Night
Biddle Oration
in Hotel Ballroom
Speaker: Alphonse Schwitalla

Dancing

Smoker

in Pantlind Hotel Ballroom

END OF
CONVENTION

June, 1941

469

DELEGATES TO MSMS HOUSE OF DELEGATES— 1941
(Names of alternates appear in italics)

Allegan

C. A. Dickinson, M.D., Wayland
IV. C. Medill, M.D., Plainwell

Alpena-Alcona-Presque Isle

W. E. Nesbitt, M.D., Alpena
A. R. Miller, M.D., Harrisville

Barry ’

Gordon F. Fisher, M.D., Hastings
/. K. Altland, M.D., Traverse City

Bay-Arenac-Iosco

C. L. Hess, M.D., Davidson Building, Bay City

Fred Drummond, M.D., Kawkawlin

R. H. Criszvell, M.D., Phoenix Bldg., Bay City

J. N. Asline, M.D., Essexville

Berrien

Don W. Thorup, M.D., Benton Harbor
Noel J. Hershey, M.D., Niles

Calhoun

Harvey Hansen, M.D., 1102 Central Tower, Battle
Creek

A. T. Hafford, M.D., Albion

Geo. W. Slagle, M.D., 1506 Central Tozver,

Battle Creek

A. A. Humphrey, M.D., Leila Hospital, Battle Creek

Branch

R. L. Wade, M.D., Coldwater
Samuel Schultz, M.D., Coldzvater

Cass

S. L. Loupee, M.D., Dowagiac

K. C. Pierce, M.D., Dozvagiac

Chippewa-Mackinac

L. M. McBryde, M.D., Sault Ste. Marie
IV. F. Mertaugh, M.D., Sault Ste. Marie

Clinton

G. H. Frace, M.D., St. Johns

W. B. McWilliams, M.D., Maple Rapids

Delta-Schoolcraft

J. J. Walch, M.D., Escanaba
W. A. LeMire, M.D., Escanaba

Dickinson-Iron

W. H. Alexander, M.D., Iron Mountain

E. B. Andersen, M.D., Iron Mountain

Eaton

Paul Engle, M.D., Olivet

F. W. Sassaman, M.D., Charlotte

Genesee,

George J. Curry, M.D., 402 Genesee Bank Building,
Flint

Donald R. Brasie, M.D., 907 Citizens Bank Bldg.,
Flint

Frank E. Reeder, M.D., 808 Genesee Bank Bldg.,
Flint

Henry Cook, M.D., 400 Sherman Bldg., Flint
Robert D. .Scott, M.D., 1215 Detroit St., Flint
A. Dale Kirk, M.D., 300 E. First St, Flint

T. S. Conover, M.D., 400 Sherman Bldg., Flint

Frank Johnson, ^.D., 319 Dryden Bldg.,. Flint

1

Gogebic

J. D. Reid, M.D., Ironwood

H. T. Nezzvorski, M.D., Ramsay

Grand Traverse-Leelanau-Benzie
Robert T. Lossman, M.D., Traverse City

H. B. Kyselka, M.D., Traverse City

Gratiot-Isabella-Clare

M. G. Becker, M.D., Edmore
W. L. Harrigan, M.D., Mt. Pleasant

Hillsdale

Luther W. Day, M.D., Jonesville

O. G. McFarland, M.D., North Adams

Houghton-Baraga-Keweenaw
C. A. Cooper, M.D., Hancock
Alfred LaBine, M.D., Houghton

Huron

C. W. Oakes, M.D., Harbor Beach
C. A. Scheurer, M.D., Pigeon

Ingham

C. F. De Vries, AI.D., 320 Townsend St., Lansing
T. I. Bauer, M.D., 301 Seymour St., Lansing
L. G. Christian, M.D., 108 E. St. Joseph St., Lansing
Robert S. Breakey, M.D., 1211 City National Bldg.,
Lansing

R. L. Finch, M.D., 124 W. Lenazuee St., Lansing
C. S. Davenport, M.D., St. Lazvrence Hospital,
Lansing

lonia-Montcalm

W. L. Bird, M.D., Greenville
C. T. Pankhurst, M.D., Ionia

Jackson

J. J. O’Meara, M.D., 608 Peoples Bank Bldg., Jackson
Horatio A. Brown, M.D., 701 Reynolds Bldg., Jackson

C. S. Clarke, M.D., 605 Dzvight Bldg., Jackson
Charles R. Dengler, M.D., 305 Carter Bldg., Jackson

Kalamazoo

I. W. Brown, IM.D., City Hall, Kalamazoo

Louis W. Gerstner, M.D., 420 John St., Kalamazoo
Wm. Scott, M.D., 716 American National Bank Bldg.,
Kalamazoo

Albert B. Hodgman, M.D., 1029]/2 W. North St.,
Kalamazoo

Kent

A. V. Wenger, M.D., 302 Loraine Bldg., Grand Rapids
Carl F. Snapp, M.D., Medical Arts Bldg.,

Grand Rapids

Geo. H. Southwick, M.D., 55 Sheldon Ave.,

S.E., Grand Rapids

A. B. Smith, M.D., Metz Building, Grand Rapids

P. W. Kniskern, M.D., Medical Arts Building,
Grand Rapids

W. L. Bettison, M.D., Medical Arts Bldg..,

Grand Rapids

Christian G. Krupp, M.D., Kendall Bldg.,

Grand Rapids

Daniel DeVries, M.D., 1414 Eastern
S.E., Grand Rapids

O. H. Gillett, M.D., 601 Metz Building, Grand Rapids
W. Clarence Beets, M.D., 2221 Jefferson Drive,
Grand Rapids

Lapeer

D. J. O’Brien, M.D., Lapeer
H. M. Best, M.D., Lapeer;,

Lenawee

A. W. Chase, M.D., Adrian
Bernard Patmos, M.D., Adrian

.470

Jour. M.S.M.S.

II

DELEGATES TO MSMS HOUSE OF DELEGATES

Xivingston

' D. C. Stephens, M.D., Howell
' D. A. Cameron, M.D., Brighton

Luce

Henry E. Perry, M.D., Newberry'

R. E. Spinks, M.D., A-ewberry

\ Macomb

D. Bruce Wiley, M.D., Utica

A. B. Bower, M.D., Armada

I Manistee

I E. A. Oakes, M.D., Manistee

I (No alternate named)

I Marquette-Alger

' V. Vandeventer, M.D., Ishpeming

I R. A. Burke, M.D., Palmer

; Mason

I W. S. Martin, M.D., Ludington
‘ V. J. Blanchette, M.D., Custer

I

I Mecosta-Osceola-Lake

Gordon Yeo, M.D., Big Rapids
Paul B. Kilmer, M.D., Reed City

! Medical Society of North Central Counties
I C. R. Keyport, M.D., Grayling
' Richard Peckham, M.D., Gaylord

; Menominee

' H. T. Sethney, M.D., Menominee
S'. C. Mason, M.D., Menominee

I Midland

Edward Meisel, M.D., Midland
(A^o alternate named)

i; Monroe

D. C. Denma, M.D., IMonroe
I /. H. McMillin, M.D., Monroe

i Muskegon

’ E. O. Foss, M.D., 502 Muskegon Bldg., Muskegon
: E. N. D’Alcom, M.D., 405 Michigan Theater Bldg.,

Muskegon

I (No alternates named)

I N ewaygo

O. D. Stryker, M.D., Fremont
W. H. Barnum, M.D., Fremont

I Northern Michigan

f Wm. S. Conway, ^I.D., Petoskey

I Walter M. Larson, M.D., Levering

I Oakland

I C. T. Ekelund, M.D., Riker Bldg., Pontiac

George A. Sherman, M.D., State Health Department,
Lansing

Richard E. Olsen, M.D., St. Joseph Mercy Hospital,
Pontiac

Z. R. Aschenbrenner, M.D., Farmington

B. T. Larson, M.D., 216 Cherokee Rd., Pontiac

C. G. Darling, M.D., Riker Bldg., Pontiac

Oceana

Merle Wood, M.D., Hart
Fred Rectz, M.D., Shelby

Ontonagon

W. F. Strong, M.D., Ontonagon

H. B. Hogue, M.D., Ezven

Ottawa

A. E. Stickley, M.D., Coopersville
R. A^ichols, M.D., Holland

JuxE. 1941

St. Clair

A. L. Gallery, M.D., Peoples Bank Bldg.,

Port Huron

D. W. Patterson, M.D., 622 Huron Avenue,

Port Huron

St. Joseph

John W. Rice, M.D., Sturgis
R. A. Springer, M.D., Centerville

Saginaw

C. E. Toshach, M.D., 333 South Jefferson, Saginaw

F. O. Novy, M.D., 420 S. Jefferson, Saginaw
(No alternates named)

Sanilac

R. K. Hart, M.D., Croswell

H. V. Norgaard, M.D., Marlette

Shiawassee

I. W. Greene, M.D., Owosso

L. F. Bates, M.D., Durand — (Deceased 4-5-41)

Tuscola

T. E. Hoffman, M.D., Yassar
W. Dickerson, M.D., Caro

Van Buren

W. R. Young, M.D., Lawton
Edwin Terwilliger, M.D., South Haven

Washtenaw

John A. Wessinger, M.D., 339 N. Washington Ave.,
Ann Arbor

Dean W. Myers, iM.D., 317 S. State Street, Ann Arbor
L. J. Johnson, M.D., 1603 Granger, Ann Arbor
C. L. Washburne, M.D., St. Joseph Mercy Hospital,
Ann Arbor

L. E. Knoll, M.D., 227 F. Liberty, Ann Arbor
R. W. Teed, M.D., 410 Highland, Ann Arbor

Wayne County

R. H. Pino, M.D., 1553 Woodward, Detroit
Gaylord S. Bates, M.D., 1553 Woodward, Detroit
Henry A. Luce, M.D., 1553 Woodward, Detroit
R. L. Novy, M.D., 5057 Woodward, Detroit
Douglas Donald, M.D., 1553 Woodward, Detoit
A. E. Catherwood, !M.D., 1553 Woodward, Detroit
T. K. Gruber, M.D., Eloise Hospital, Eloise
W. D. Barrett, M.D., 1553 Woodw'ard, Detroit
T. ^L Robb, M.D., 1553 Woodward, Detroit
'R. M. McKean, M.D., 1553 Woodward, Detroit
Allan ;McDonald, M.D., 5057 Woodward, Detroit
H. J. Kullman, M.D., 1553 Woodward, Detroit
L. T. Hirschman, M.D., 7815 E. Jefferson, Detroit

E. b. Spalding, M.D., 5057 Woodward, Detroit

G. C. Penberthy, M.D., 1553 Woodward, Detroit

G. L. :McClellan, M.D., 2501 W. Grand Blvd.,
Detroit

W. B. Cooksey, IM.D., 62 W. Kirby Avenue, Detroit
C E Dutchess, M.D.. Parke, Davis & Co., Detroit

E. A. Osius, M.D., 2799 W. Grand Blvd., Detroit
T. H. Andries, M.D., 1553 Woodward, Detroit

R. C. Tamieson, M.D., 1553 Woodward, Detroit

L. T. Henderson, M.D., 13038 E. Jefferson, Detroit
C. S. Kennedy, M.D., 10 Peterboro, Detroit

H. F. Dibble, M.D., 1553 Woodward, Detroit

S. W. Insley, M.D., 5057 Woodward, Detroit
P. L. Ledwidge, IM.D., 1553 Woodward, Detroit
C. F. Brunk, M.D., 7815 E. Jefferson. Detroit
Wm. S. Reveno, M.D., 3001 W. Grand Blvd., Detroit
C. F. Vale, M.D., 1553 Woodward, Detroit

F. W. Hartman, M.D., 2799 W. Grand Blvd., Detroit
R. V. Walker, M.D., 1553 Woodward, Detroit

H. W. Plaggemeyer, M.D., 1553 Woodward, Detroit
C. E. Simpson, M.D., 74 W. Adams, Detroit

J. A. Kasper, M.D., 1151 Taylor Ave., Detroit

471

SUPPLEMENTARY ROSTER

I

A. F. Jennings, M.D., 7815 E. Jefferson Ave., Detroit
L. J. Morand, M.D., 1553 Woodward, Detroit

C. K. Hasley, M.D., 1553 Woodward, Detroit

B. L. Connelly, M.D., 5057 Woodward, Detroit

C. E. Lemmon, 1553 Woodward, Detroit

E. R. Witwer, M.D., 3839 Brush St., Detroit
L. W. Hull, M.D., 1553 Woodward, Detroit
John H. Law, M.D., 4160 John R. St., Detroit
Wm. P. Woodworth, M.D., 2501 W. Grand Blvd.,

Detroit

L. O. Geih, M.D., 3528 Van Dyke, Detroit
Wm. H. Honor, M.D., 2966 Biddle, Wyandotte

L. J. Gariepy, M.D., 16401 Grand River, Detroit

M. H. Hoffmann, M.D., Eloise Hospital, Eloise
Arch Walls, M.D., 12065 Wyoming, Detroit

S. E. Gould, M.D., Eloise Hospital, Eloise

H. B. Fenech, M.D., 10 Peterboro, Detroit

W. B. Harm, M.D., 5884 W. Vernor Highway, Detroit

F. A. Weiser, M.D., 1553 Woodward, Detroit

C. S. Ratigcm, M.D., 22340 Michigan, Dearborn
Edward Cathcart, M.D., 1553 Woodward, Detroit

D. I. Sugar, M.D., 17 Brady St., Detroit

H. C. Hack, M.D., 3001 W. Grand Blvd., Detroit
B. H. Priborsky, M.D., 5057 Woodward, Detroit

H. K. Shawan, M.D., 1553 W oodward, Detroit
W. A. Chipman, M.D., 14902 Grand River, Detroit

C. J. Jentgen, M.D., 2501 W. Grand Blvd., Detroit

V. N. Butler, M.D., 3001 W. Grand Blvd, Detroit

E. D. King, M.D., 5455 W. Vernor Highway, Detroit

E. E. Martmer, M.D., 1553 Woodward, Detroit
J. B. Rieger, M.D., 1553 Woodward, Detroit

D. C. Somers, M.D., 8445 E. Jefferson, Detroit
R. J. Schneck, M.D., 1553 Woodwa/rd, Detroit

F. C. Witter, M.D., 2905 W. Grand Blvd., Detroit

W. N. Braley, M.D., 12897 Woodward, Detroit

R. A .C. Wollenberg, M.D., 1553 Woodward, Detroit
R. A. Johnson, M.D., 7815 E. Jefferson, Detroit
L. W. Shaffer, M.D., 1553 Woodward, Detroit
D. J. Barnes, M.D., Vet. Admin. Facility, Dearborn
F. H. Top, M.D., 1151 Taylor Ave., Detroit
A. V. Forrester, M.D., 16491 Woodward, Detroit
Wm. Hamilton, M.D., 13836 Woodward, Highland
Park

A. H. Bracken, M.D., 13102 W. Warren, Dearborn
Wexford

W. Joe Smith, M.D., Cadillac
John Gruber, M.D., Cadillac

SUPPLEMENTARY ROSTER

The following members were certified to the Secre-
tary of the Michigan State Medical Society after the
Roster which appeared in the May issue of The

Journal had gone

to press.

Alpena-Alcona-Presque Isle

Trudeau, J. M

Frederickson, H. C. .

Berrien County

Henthorn, A. C

Clinton

MacEachran, Hugh. .
Walker, Claude

Dickinson-Iron

Iron Mountain
Iron Mountain

Burnell, B. E

Graham, Hugh

Van Gorder, George.
White, Perry

Genesee

Pierpont, D. C

Gogebic

Houghton-Baraga-Keweenaw

Aldrich. L. C Hancock

Wickliffe, T. P " Calumet

Botting, A. E

Robertson, Perry C..

lonia-Montcalm

Myers, J. H

Jackson

Brown, I. W

Hobbs, E. J

Kalamazoo

Diamond. F. J

Gibbs, Floyd

Houghton, G. D

Lavan, John

Rasmussen, Leo

Smith, Edwin M. . . .

Kent

.Grand Rapids

..Toledo, Ohio
. Grand Rapids
. Grand Rapids

Claflin, G. M

Growt, B. H

Lennox, A. L

McCite, F. J

Rogers, J. D

Lenawee

Drury, Charles

Howe, L. W

Sicotte, I

Vandeventer, V

Marquette-Alger

Hoffman, H. B..
Kirwan, E. J. . . .
Ostrander, R. A.

Moriarty, Walter.

Johnstone, K. T.

German, Frank D.

Jensen, V. W. ..

House, M. E. . . .
Tappan, W. M. ..

Porter, C. G

Diephuis, Bert...
Greenman, N. H.

Barnwell, John

Barr^ Albert S

Curtis, Arthur C

Emerson, Herbert W. . .

Farris, Jack M

Field, Henry, Jr

Gates, Neil A., Jr

German, James W

Hammond, George

Hammond, George W. .

Himler, Leonard E

Howes, Homer A

Malamud, Nathan

Raphael, Theophile

Riggs, Harold W

Snow, Glenadine

Waldron, Alexander M.

Mason

Monroe

N eway go
Oakland

Oceana

Ottawa

St. Joseph
Van Buren

Washtenaw

Wayne

Altman, Raphael

Axelson, A. U

Balaga, Frank T

Bates, Gaylord S

Bogusz, Ladislaus

Broudo, Philip H

Brownell, Paul G

Carroll, Elmer H

Conley, L. C. M

Cotton, Schuyler O

Dunn, Cornelius E

Fenner, W. A

Forrester. Alex V

Fowler Wm

Garner, H. B

Gemeroy, Joseph C

Hanser, Joshua

(Continued on Page 478)

Ludington

Ludington

Ludington

Monroe
. .Grant

Pontiac

Shelby

Holland

Holland

. . . Centerville

South Haven
Decatur

Ann Arbor
. Ann Arbor
Ann Arbor
. Ann Arbor
.Ann Arbor
.Ann Arbor
.Ann Arbor
. . . Ypsilanti
.Ann Arbor
• Ann Arbor
.Ann Arbor
.Ann Arbor
.Ann Arbor
.Ann Arbor
.Ann Arbor
. . .Ypsilanti
.Ann Arbor

.Detroit
Detroit
Detroit
Detroit
. .Eloise
Detroit
Detroit
.Detroit
Detroit
Detroit
Detroit
Detroit
Detroit
Detroit
Detroit
Detroit
Detroit

472

Tour. M.S.M.S.

-K

MICHIGAN'S DEPARTMENT OF HEALTH

HENRY A. MOYER, M.D., Commissioner, Lansing, Michigan

-K

50,000 CASES OF MEASLES

Measles cases reported to the Michigan Department
of Health by the end of April totaled more than 50,-
000. Comparisons for the 1941 epidemic and those of
1938 and 1935 follows:

Jan. -Apr., 1935 47,955

Jan. -Apr., 1938 53,226

Jan.-Apr., 1941 53,172

In both the previous two epidemics, the cases at the
end of the year totaled 80,000, and so it is quite pos-
sible that as many cases will be reported this year.
Cases are being reported from all parts of the state,
with Detroit reporting almost a third of the total in
March and April. The figures for the two months are :
March, Detroit 5,187, rest of state 13,821, total 19,-
008 ; April, Detroit 4,028, rest of state 14,141, total
18,169.

Although the reported number of cases of measles is
about the same as in 1938, it is likely that this year
individual protection for babies and young children
has been better than in the last epidemic. Physicians
in many instances are finding immune globulin useful
in making an attack of measles shorter and lighter.
If the attack is modified successfully, complications are
rare, and it is the complications that cause most measles
deaths. Whether or not to give the protecting treat-
ment be left to the judgment of the physician. To be
effective, it must be given by the eighth day after
exposure to a case of measles, which is before symp-
toms develop.

COMMUNICABLE DISEASE
COMPARISON

Reported cases of certain communicable diseases for
the first three months of the year show only two dis-
eases to be appreciably higher than for the first quar-
ter of 1940. These are measles and whooping cough.
Lobar pneumonia continued low, scarlet fever and tu-
berculosis were both down and syphilis and gonorrhea
were about the same.

The figures for twelve communicable diseases fol-
low :

Lobar pneumonia
Tuberculosis ....
Typhoid fever . .

Diphtheria

Whooping cough
Scarlet fever . . .

Measles

Smallpox

Meningitis

Poliomyelitis ....

Syphilis

Gonorrhea

First Quarter

of Year

1941

1940

. . 1,014

1,089

. . 1,0'88

1,311

27

23

66

81

. . 4,213

1,569

. . 3,037

3,959

. . 35,003

3,534

32

7

10

16

11

8

.. 2,201

2,432

.. 1,628

1,636

KAHN TESTS SET NEW RECORD

Blood tests for syphilis are at new high monthly
totals for Michigan. The total for March for public
arid private laboratories was 89,002, a record. The
previous high was 85,782 in October.

Michigan Department of Health laboratories are
making more Kahn tests than ever before, the increase
being due largely to work done for Selective Service

(DUE TO NEISSERIA GONORRHEAE)

efn

ilver Picrate,
Wyeth, has a convincing record of
effectiveness as a local treatment for
acute anterior urethritis caused by
Neisseria gonorrheae.^ An aqueous
solution (0.5 percent) of silver pic-
rate or water-soluble jelly (0.5 per-
cent) are employed in the treatment.

Acomplete techniqueof treatment and literature will be sent upon request

♦Silver Picrate is a definite crystalline compound of silver and picric acid.
It is available in the form of crystals and soluble trituration for the prepara-
tion of solutions, suppositories, water-soluble jelly, and powder for vaginal
insufflation.

1. Knight, F., and Shelanski,
H. A., "Treatment of Acute Ante-
rior Urethritis with Silver Picrate,”
Am. J. Syph., Gon. & Ven. Dis.,
23, 201 (March), 1939.

JOHN WYETH & BROTHER, INCORPORATED, PHILADELPHIA

June, 1941 473

Say you saw it in the Journal of the Michigan State Medical Society

MICHIGAN’S DEPARTMENT OF HEALTH

in the Lansing and Grand Rapids laboratories of the
Department.

For the first three months of the year, the De-
partment’s Kahn tests were at higher levels than
ever before, and the March total of 36,539 exceeded
the total tests made in private laboratories for the
first time since comparative records have been avail-
able. Private laboratories performed 32,940 Kahn
tests in March and city health department labora-
tories aided by state funds made 19,523 tests. In
the previous high month of October, the totals were:
State Health Department laboratories 18,443, sub-
sidized city health department laboratories 18,143,
private laboratories 49,196.

MARRIAGES INCREASE 23 PER CENT

After a two-year slump in weddings, marriages
showed a 23 per cent gain in 1940. The total was
46,342, compared with 37,725 in 1939 and 30,105 in
1938. The gain of 23 per cent was the third largest
percentage increase in marriages since the 37 per cent
gain in 1919, when American soldiers returned from
France and from cantonments.

“Industrial booms and the approach of the draft
were undoubtedly an influence in the increase in mar-
riages, particularly in the second half of the year,’’
said Commissioner Moyer.

SAGINAW SURVEY FINDS
ELEVEN NEW CASES

Eleven previously unrecognized cases of tuberculosis
were discovered recently in a week’s case-finding pro-
-gram at Saginaw, sponsored by the city health depart-
ment and endorsed unanimously by the Saginaw Coun-
ty Medical Society. The area covered was the city’s
first ward, where in the last five years, 45 out of Sagi-
naw’s 148 tuberculosis deaths had occurred.

Films were read by Dr. George A. Sherman, direc-
tor of the Department’s Bureau of Tuberculosis Con-
trol, and a nearly complete check of the work shows
these clinically significant results :

Minimal cases 7

Moderately advanced 3

Far advanced 1

The photo x-ray truck was placed at a fire station
for the case-finding, and efforts were made to get a
chest film for every person in the ward over ten years
of age. The population of the first ward is about
5,000, and 1,000 films four by five inches were made.
It is believed that two-thirds of the persons eligible
came to the truck for x-rays.

Families living in this ward are largely Mexican and
Negro and the eleven cases found w’ere in these races.
(All of the 45 tuberculosis deaths in the ward in the
last five years were among Mexican and Negro per-
sons.)

HAY FEVER IMMUNITY TREATMENTS

Hay fever sufferers who are relieved by immunity
treatments have been reminded by the Michigan De-
partment of Health that now is the time to see their
physician. In a newspaper release at the end of April,
the following paragraph appeared :

“Immunity to pollens that cause hay fever can often
be built up by injections given just under the skin
by a physician. The doses are usually gradually in-
creased, and most doctors like to start them two or
three months before the protection is needed. For
those whose hay fever is due to ragweed pollen, the
most common cause, immunizing injections should begin
now, since the ragweed season starts in August.”

SAFE WATER

Physicians in Michigan who had a part in the cam-
paigns of past years for safe public water supplies will
be interested in knowing that such campaigns are still
being made. Litchfield, a Hillsdale county village of
717, recently voted 197 to 55 to bond for $30,000 as
the sponsor’s share of a $73,000 WPA project which
will provide a water works system, with well, pump-
ing station, elevated tank and mains. The proposal
had previously been rejected, late in 1940, but an
energetic civic campaign brought about a four to one
favorable vote in March.

No incorporated place of 1,000 or more population in
the state is without a public water supply, but smaller
towns are still building water systems or improving
the ones they have.

MATERNAL MORTALITY
AT NEW LOW

Michigan’s maternal mortality rate for 1940 is the
lowest the state has known. The figure is 2.92 deaths
per 1,000 live births, compared with 2.97 in 1939, and
6.04 in 1930.

Maternal deaths in 1940 totaled 290, in connection
with 99,139 births. In 1939 there were 280 maternal
deaths and 94,432 births.

“Substantial improvement in the maternal death rate
has come about only in the last ten years,” Commis-
sioner Moyer said. “In 1930 the rate of 6.04 was
little better than it was ten or even 20 years before.
A decline in the rate which started in 1930 has con-
tinued ever since, and the rate now is half what it
was ten years ago.

“With the present emphasis of the medical profes-
sion on postgraduate education and higher .standards
of medical care, we can expect that the maternal rate
will go even lower in the future.”

Previously, a new low infant mortality record had
been announced for 1940. The rate was 40.7 deaths
of infants under a year old per 1,000 live births. The
1939 infant death rate was 41.9.

PONTIAC DEPARTMENT
IN NEW LOCATION

The Health Department of the City of Pontiac has
moved from the Pontiac General Hospital to a more
central location in the downtown Hubbard Building.
This move should prove advantageous to the physicians
in Pontiac, as well as to the public.

EXAMINATION FOR ASSISTANT SURGEON

The next examumtion for Assistant Surgeon in the
regular Navy will be held at all major Naval Medi-
cal Department Activities on August 11 to 15, in-
clusive, and for Acting Assistant Surgeon on June
23 to 26 inclusive. Students in class “A” medical
schools who will complete their medical education
this year are eligible to apply for these appointments,
and if successful will receive their appointments ap-
proximately two months after the date of the ex-
amination. A circular of information listing physical
and other requirements for appointment as Acting
Assistant Surgeon, subjects in which applicants are
examined, application forms, etc., maj' be obtained
from the Bureau of Medicine and Surgery, Navy De-
partment, Washington. D. C., upon request.

474

Tour. M.S.M.S.

^ Woman’s Auxiliary -K

Bay County

The Woman’s Auxiliary to the Bay County Medical
Society held its annual meeting and election of officers
at the Wenonah Hotel on March 12.

Mrs. W. R. Ballard was re-elected president; Mrs.
G. M. Brown, president-elect; Mrs. W. S. Stinson,
vice president; Mrs. K. A. Alcorn, secretary; Mrs. Paul
DeM^aele, corresponding secretary; and Airs. H. M.
Gale, treasurer.

The group decided to elect the officers for a two-
year term in the future.

Mrs. P. R. Urmston was chairman of the nominat-
ing committee, assisted by Mrs. R. C. Perkins and Mrs.
E. S. Huckins.

Annual reports for 1940 were given by the secretary,
Mrs. C. W. Reuter and the treasurer, Mrs. H. M. Gale.

Since we have a good balance in our treasury, we are
planning to donate some mone)' to the American Red
Cross and a local organization — the amounts to be de-
cided at our April meeting. Mrs. F. T. Andrews was
appointed to look into the matter and report at the
next meeting.

The members made tentative plans to entertain the
Saginaw and }^lidland auxiliaries in May. The presi-
dent is appointing a committee to take charge of this
party.

Mrs. F. V. Kowals, a guest, was introduced as a
prospective new member.

Dr. P. R. Urmston, President of the Michigan State

Medical Society, addressed the Auxiliary. He gave a
detailed account of the work of the county and city
health departments and discussed current medical leg-
islation with special reference to medical care to the
indigents and low income groups.

There were twenty-one present at the meeting.

Mrs. J. Norris Asline.

* *

At the meeting on April 9, 1941, at the Wenonah
Hotel, eighteen were present at dinner which was fol-
lowed by a business meeting and program.

Mrs. W. R. Ballard, who was recently reelected
president of the Auxiliary, presided and announced
appointments of committees for the coming year.

Mrs. Kenneth R. Stuart was appointed treasurer
to fill the vacancy created by the resignation of
Mrs. H. M. Gale, who has held the office for sev-
eral years. Mrs. Gale was presented with a cor-
sage.

Tuesday, May 13, 1941, was chosen as the date to
entertain the members of the Saginaw and Midland
auxiliaries as well as guests from nearby small
towns at a tea to be held at the Bav Citv Country
Club.

Mrs. W. S. Stinson presented the program and
Mrs. Virgil Schultz gave an interesting review of
Ernest Hemingway’s book “For Whom the Bell
Tolls.”

Dr. F. T. Andrews invited the auxiliarj^ members
to take part in the all-day Mental Hj'giene insti-

NATIONAL ASSOCIATION OF CHEWING GUM MANUFACTURERS, STATEN ISLAND. NEW YORK

A friendly suggestion:

Your 'dirtiest” patients aren’t the only ones. Doctor,

who enjoy wholesome CHEWING GUM

enjoyment of delicious chew-
ing gum is a real American custom
— probably because chewing is such
a basic, natural pleasure.

Enjoy chewing gum yourself. See how
the chewing helps relieve tension by

giving it a try during your busy days.

Have some gum in your pocket or bag
and in the office. Your patients — children
and adults — appreciate your friendliness
when you offer them some. Try this for a
month — you’ll be pleased with the results.

Tune, 1941

Say you saw it in the Journal of the Michigan State Medical Society

475

WOMAN’S AUXILIARY

tute to be held in Bay City on April 30, 1941, at the
Wenonah Hotel and Dr. L. Fernald Foster ex-
plained the Michigan seal sale campaign for crip-
pled children in which the auxiliary has taken part.
— Mrs. Paul L. DeWaele.

Genesee County

The regular meeting of the Woman’s Auxiliary of
the Genesee County Medical Society was held on March
18 at Hurley Nurses Home, The board meeting was
followed at 1 :30 p. m. by the regular meeting with
about 35 members present.

The meeting was in charge of Mrs. B. F. Sniderman,
chairman of program for the day. She presented Dr.
Ray Morrish who gave a very interesting talk on Public
Relations. Following this the president Mrs. J. H. Cur-
tin called the business meeting to order and minutes
from the last meeting and the board meeting were read
and approved. Reports of standing committees were
then read and approved. The nominating committee
submitted the following slate : President, Mrs. W. B.
Hubbard; President-Elect, Mrs. Stephen Gelenger;
Vice President, Mrs. Lafon Jones ; Secretary, Mrs.
Hira Branch; Treasurer, Mrs. B. A. Schiff.

The proposed slate was unanimously elected and the
newly elected officers installed.

A gift was presented to Mrs. Curtin, the retiring
president, and the business meeting adjourned. Tea
followed with Mrs. W. P. Boles and Mrs. James Row-
ley presiding at the tea table centered with spring flow-
ers in yellow and red and tall ivory tapers.

Mrs. Stephen Gelenger was chairman of the day as-
sisted by the following committee, Mesdames Eugene
Smith, James Rowley, W. P. Boles, Harold Woughter,
Frank Baske, Geo. Anthony, Floyd Steinman and Flem-
ing Barber. — Bernice R. Wright.

Genesee County (Contd.)

A board meeting of old and new members preceded
the luncheon at the Flint Tavern, April 22. Mrs. O. J.
Preston was in charge of the program featured with
an address by Dr, L. O. Shantz, who spoke on “Med-
ical Economics.”

Mrs. W. B. Hubbard, president of the auxiliary,
named the following new board; Membership, Mrs.
D. R. Brasie; Social; Mrs. Arthur Kretchmar ; Pro-
gram, Mrs. Preston; Courtesy, Mrs. K. R. Sandy;
Press, Mrs. N. A. Gleason; Welfare, Mrs. George
Anthony ; Finance, Mrs. T. S. Conover ; Legisla-
tion and Health, Airs. Gordon Willoughby; Tele-
phone, Mrs. Frank Ware; Historian, Mrs. Harold
Woughter; Auditing, Mrs. Henry Cook and Mrs,
F. E. Reeder; Revision, Mrs. C. W. Colwell; Health
Magazine, Mrs. E. C. Smith; Red Cross, Mrs. Alvin
Thompson and Mrs. James Olson; British Relief,
Mrs. Arthur McArthur and Mrs. Isadore Gutow;
National Bulletin, Mrs. J. H. Curtin; Parliamen-
tarian, Mrs. M. E. Chandler.

Plans were discussed for Red Cross and British
relief projects and announcement was made of a
joint meeting to be held with the Genesee County
Medical Society at Hotel Durant, Tuesday, May
27, when Dr. Preston Bradley, Chicago, pastor
of the People’s Church, will be the speaker — (AIrs.
N. A.) Margaret A. Gleason.

Houghton-Eeweenaw-Boraga Counties

The monthly meeting of the Ladies’ Auxiliary to
the Houghton-Keweenaw-Baraga County Medical So-
ciety met at the Miscowaubik Club, Calumet, April 1.
A business meeting, presided over by Mrs. T. P. Wick-
liffe, was devoted to a discussion of plans for the Tea
and Style Show for the benefit of the Copper Country

WEHENKEL SAXATORICM

A MODERN, comfortable sanatorium adequately equipped for all types of medical and ■
surgical treatment of tuberculosis. Sanatorium easily reached by way of Michigan
Highway Number 53 to Comer of Gates St., Romeo, Michigan.

For Detailed Information Regarding Rates and Admission Apply

DR. A. M. WEHENKEL« Medical Director, City Offices, Madison 3312*3

476

Say you saw it in the Journal of the Michigan State Medical Society

Jour. AI.S.AI.S.

WOMAN’S AUXILIARY

Sanatorium to be held at the Calumet Armory, April
19th.

Mrs. A. B. Aldrich was chairman of the committee in
charge of the Style Show and Mrs, A. C. Roche was in
charge of arrangements for the Tea.

The program for the meeting was a review of the,
“Life and Work of a Woman Surgeon,” by Rosalie
Slaughter Morton, delightfully interpreted by Mrs. L.
E. Coffin.

Ingham County

I The Ingham County Medical Auxiliary held its
April meeting Monday the 21st, at the home of
Mrs. F. J. Cushman. Our principal speaker of the
afternoon was the State Commander of the Wom-
en’s Field Army for the Control of Cancer, Mrs.
John Wierango of Grand Rapids. Mrs. Wierango
gave the history of this organization and outlined
their extensive program. The members were given
the opportunity to join the Cancer Control Army
and thus promote their work for payment of dues.

The second speaker of the afternoon was Mrs.
Cameron Murdock of Kalamazoo, who gave a most
interesting talk on Tahiti where she had spent a
i year gathering material for a book; the talk was il-
lustrated with beautiful artist’s drawings of na-
tives. their homes and customs.

1 For our active Red Cross work, we voted to as-
sume the payment for, and making of, Ingham
County’s entire quota of obstetrical units for
England. This assignment which consists of some
1400 items, was under the direction of Mrs. Wil-
liam J. Cameron. We are happy to report that this
large project has been completed and is packed
I awaiting shipment.

I The auxiliary invited the wives of visiting doc-
I tors attending the Society’s annual clinic on May
I 1, for dinner and evening entertainment at the
j Country Club of Lansing. — Margaret S. Davenport.

I Jackson County

The regular monthly meeting of the Medical
Auxiliary to the Jackson County Medical Society
was held Tuesday evening March 18 at the home
of Mrs. T. E. Schmidt. A delicious dinner was
served to forty-two members by the following
committee : Mesdames John Smith, C. S. Clark, D.
W. Smith, J. W. Speck, S. Sugar, C. W. Schepler,
J. H. Myers, G. D. Culver, L. L. Stewart, and J.
W. Townsend.

j Mrs. N. M. Stewart, chairman for the evening,

I presented Mrs. Osmar Gallinger of Hartland, Mich-
{ igan, who gave a very interesting illustrated lec-
ture on weaving. This old American custom is
being revived and Mrs. Gallinger invited the mem-
bers to come to Hartland and learn to weave.

The next meeting of the Auxiliary will be held
May 20 at the home of Mrs. M. J. McGlaughlin and
Mrs. Charles Dengler will give her revue of Jenny
Lind.

Kalamazoo County

Miss Pearl Schoolcraft, principal of the North West-
' nedge Avenue School 'was the speaker at the March
I meeting of the Women’s Auxiliary to the Kalamazoo
Academy of Medicine. Her subject was, “The Value
of a Flexible Program in Our Schools.”

I Mrs. B. A. Shepard was the hostess, assisted by Mrs.
I John Fopeano and Mrs. Wm. Kavanaugh. The twenty-
! five menibers present enjoyed a most delightful dinner.
Spring flowers were used for decorations.

* * *

1 The April meeting was held at the home of Mrs.
John Volderauer. Mrs. Ralph Cook and Mrs. Roscoe
Hildreth assisted the hostess.

Frances Rigterink.

Smoother.

THESE BABY FOODS

ARE EXTRA EASY
TO DIGEST

(Statement accepted by the
AM A Council on Foods)

*Not merely strained like other baby
foods, but strained and then specially
homogenized. That is why Libby’s Baby
Foods — vegetables, fruits, cereal, soups
— are so unusually smooth and fine in
texture, extra easy to digest. Special
homogenization is an exclusive Libby
process that breaks up cells, fibers and
starch particles, and releases nutriment
for easier digestion. U. S. Pat. No. 2037029.

PEAS CARROTS SPINACH
VEGETABLE COMBINATIONS:

No. 1 — Peas, Beets, Asparagus; No. 2 — Pumpkin,
Tomato, Green Beans; No. 3 — Peas, Carrots, Spin-
ach; No. 9 — Peas, Spinach, Green Beans; No. 10—
Tomato, Carrots, Peas.

FRUIT COMBINATIONS:

No. 5 — Prunes, Pineapple Juice, Lemon Juice; No. 8
— Bananas, Apples, Apricots
CEREAL 2 SOUPS EVAPORATED MILK
ALSO Libby's Chopped Foods for older babies (10
varieties).

June, 1941

Say you saw it in the Journal of the Michigan State Medical Society

477

WOMAN’S AUXILIARY

Ferguson - Droste - F erguson Sanitarium

*

Ward S. Farcuaon, M. D. Jamas C. Drosta, M. D. Ljmn A. Farruson, M. D.

4*

PRACTICE LIMITED TO
DIAGNOSIS AND TREATMENT OF

DISEASES OF THE RECTUM

*

Sheldon Avenue at Oakes

GRAND RAPIDS, MICHIGAN
Sanitarium Hotel Accommodations

A cooperative dinner was enjoyed by the thirty
members present. Following the business meeting,
bridge was played. — (Mrs. G. H.) Fr.ances Rigter-

INK.

Kent County

Seventy-five members of the Woman’s Auxiliary
to the Kent County Medical Society attended the
annual tea which was held on April 9 at the lovely
home of Mrs. Reuben Maurits.

During the afternon, Mrs. Leo J. Dornbos, pian-
ist, Mrs. Donald D. Armstrong, mezzo-soprano, and
Mrs. Kenneth R. Edwards, harpist, entertained
with a most delightful program.

We are happy to have as honor guests, Mrs.
Roger V. Walker, State Auxiliary President, and
Mrs. H. L. French, Treasurer of the State Organ-
ization.

On May 14, the Auxiliary will hold the annual
luncheon meeting at Kent Country Club. Arrange-
ments are in charge of Mrs. A. B. Thompson, Jr.,
assisted by Mrs. Carl Snapp. Our guest speaker
will be Dr. P. L. Thompson, president of the
Kent County Medical Society. — (Mrs. R. S.) Eliz-
abeth Van Bree.

Wayne County

The April meeting of the Woman’s Auxiliary to
the Wayne County Medical Societ}'- was held on
April 18, at the Society’s Club rooms.

Following the business meeting a program on
“Gardens and Gardening” was presented by Mrs.
Patricia Roberts, assisted by Miss Violet Hodges.

During the program various arrangements of
flowers were made which were presented to mem-
bers of the audience. A most pleasant and instruc-
tive afternoon was enjoyed by everyone pres-
ent.— Margaret Wallace.

SUPPLEMENTARY ROSTER
Wayne County

(Contimied from Page 472)

Henderson, James L ....Detroit

Kasabach, V. Y Detroit

Kasper, Joseph A Detroit

Knapp, Floyd B Detroit

Kraft, Raymond B Detroit

Kuhn, Richard F Detroit

Lampman, Harold H Detroit

Leipsitz, Louis S Detroit

Levitt, Edward J Detroit

Madsen, -Martha Eloise

Mair, Harold U Detroit

Martin, Wm. C Detroit

McMahon, Gerald H Detroit

Myers, George P Detroit

Noth, Paul H Detroit

Reed, Ivor E Detroit

Robbins, Edward R Detroit

Roth, Edward T Detroit

Schmidt, Harry E Detroit

Scott, James W Detroit

Shankwiler, Reed A Detroit

Spero, Gerald D Detroit

Sugar, David I Detroit

Walters, Albert G Detroit

Weiss, Joseph G Detroit

Wells, Martha Detroit

Weston, Earl E Detroit

Wexford-Missaukee

Carrow J. F Marion

Correction. — The name of Frank D. German, M.D.,
Pontiac, who is a member of the Oakland County
Medical Society, was inadvertently omitted from the
Roster of MSMS members published in the May issue
of The Journal.

Charles C. Merkel, M.D., should have been listed
from Grosse Pointe Farms instead of Grosse Pointe in
the Roster.

478

Say you sazv it in the Journal of the Michigan State Medical Society

Jour. :M.S.M.S.

IN MEMORIAM

|ln Jllcmoriaitt

Charles W. Edmunds, M.D., of Ann Arbor, was
born in Bridport, Dorset, England, on February 22,
1873, and was graduated from the University of Michi-
gan Medical School in 1901. Doctor Edmunds had been
on the University of Michigan faculty since 1902 and
was professor and chairman of the department of ma-
teria medica and therapeutics since 1907. From 1913
to 1921 he was assistant dean of the University Medical
School. He was the oldest member of the medical
school faculty in years of service. Doctor Edmunds
died March 1, 1941.

^ ^ ^

Maxwell Nathaniel Frank, of Detroit, was born
in New York City forty-seven years ago. He was
graduated from the Detroit College of Medicine
and Surgery in July, 1917. After graduation, Doc-
tor Frank located in Detroit where he practiced
medicine for twenty-five years. Doctor Frank died
in Miami Beach, Florida, on April 1, 1941, of in-
juries received in an automobile accident several
months previously.

* sK *

Edwin B. Forbes, of Detroit, was born in Lowell,
Mass., in 1874, and was graduated from the Har-
vard Medical School in 1898. A long-time practi-
tioner in Detroit, Doctor Forbes was associated
with the L. A. Young Industries and had served
as County Physician for eight years. During the
World War, he was medical officer of the 55th
Infantrv, holding the rank of Major. He died April
15, 1941.

♦ *

P, R. Hungerford, of Concord, was born March
12, 1875, in Marshall, Michigan, and was graduated
from the University of Michigan Medical School
in 1902. He served as president of the Jackson
County Medical Society in 1929. Despite the handi-
caps from a parathyroid tetany which developed
some twelve years ago. Dr. Hungerford maintained
a general practice in Concord and availed himself
of every opportunity to take postgraduate work
at the University of Michigan and was a constant
attendant at the spring and fall clinics conducted
by the state society, as well as county medical and
staff meetings. Dr. Hungerford died May 3, 1941.

* *

W. Paul Petrie, of Caro, was born December 25,
1899 at Fairview, Kentucky, the son of the late Dr.
and Mrs. William S. Petrie, and was graduated
from the Vanderbilt University, Nashville, Tennes-
see, in 1925. He took his internship at Hillman
Hospital, Birmingham, Alabama, and later became
resident physician at Grace Hospital in Detroit.
In 1928 Doctor Petrie located in Caro where he
remained until the time of his death.

Doctor Petrie was secretary of Tuscola County
Medical Society in 1939 and in 1941 served as its
president. He was the first Caro physician to
serve on the Draft Board for Army induction. He
was a member of the Caro school board, a charter
member and past president of the Exchange Club
and was active in many other organizations. He
died May 14, 1941.

* ^ ♦

Eugene Smith, Jr., of Detroit, was born in 1887
in Detroit and was graduated from the Detroit Col-
lege of Medicine in 1912. He specialized in eye,
ear, nose and throat work. In 1915, Doctor Smith

June, 1941

Good

Treatment

for

Your Taste

If your taste responds to
smooth mellowness, Johnnie
Walker is indicated.

★

ITS SENSIBLE TO STICK WITH

Johnnie

f^LKER

BLENDED SCOTCH WHISKY

CANADA DRY GINGER ALE, INC., NEW YORK, N. Y.
SOLE IMPORTER

Say you sazv it in the Journal of the Michigan State Medical Society

479

IN MEMORIAM

DeNIKE sanitarium, Inc.

Established 1893

EXCLUSIVELY for the TREATMENT

OF

ACUTE and CHRONIC ALCOHOUSM

Mild Neuropsychic Cases
Admitted

1571 East lefferson Avenue
Cadillac 2670 Detroit

A. JAMES DeNIKE, M.D.

Medical Superintendent

became medical examiner for the civil service com-
mission, a position he held until the time of his
death. During the World War, he was attached
to Base Hospital Unit 36, served in France as a
Medical Corps major and held a commission as
lieutenant-commander in the Naval Reserve. He
was a member of the staffs of Woman’s Hospital
and St. Mary’s Hospital. He died May 20, 1941.

♦ ♦ ♦

L, H. Stewart, of Kalamazoo, was born in Kent
County, near Grand Rapids on January 9, 1858. He
was educated at Kalamazoo College and was grad-
uated from the University of Michigan Medical
School in 1897. Doctor Stewart served as a mem-
ber of the board of trustees of Kalamazoo College
from 1911 until the time of his death; as a mem-
ber of Kalamazoo township board of education for
four years. For his services he was awarded an
honorary doctor of science degree from the Kala-
mazoo College. He had charge of the SATC
medical work during the World War. Dr. Stewart
served as president of Kalamazoo Academy of
Medicine in 1918. He died April 21, 1940.

* * *

Arthur E. West, of Kalamazoo, was born in
Nebraska, May 24, 1873. He was graduated from
the University of Michigan Medical School in 1897
and took postgraduate work in Urology in New
York. He located in Kalamazoo, where he practiced
for thirty years. He had been a patient in Bron-
son Hospital for three months before his death on
April 22, 1941.

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The Wassermann and Kahn Tests

Blood Chemistry

Bacteriology and Clinical Pathology

Basal Metabolism

Aschheim-Zondek Pregnancy Test

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Electrocardiograms

Central Laboratory

Oliver W. Lohr, M.D., Director

537 Millard St.

Saginaw

Phone, Dial 2-3893

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Physicians' Service Laboratory

608 Kales Bldg. — '
Northwest comer of
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Blood Count

Complete Blood Chemistry
Tissue Examination
Allergy Tests
Basal Metabolic Rate
Autogenous Vaccines

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Complete Urine Examina-
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Ascheim-Zonde

(Pregnancy)

Smear Examination
DarkBeld Examination

All types of mailing containers supplied.
Reports by mail, phone and telegraph.
Write for further information and prices.

480

Say you saw it in the Journal of the Michigan State Medical Society

Jour. M.S.M.S.

-X COUNTY AND PERSONAL ACTIVITIES -x

100 per cent Club for 1941

Allegan

Menominee

Barry

Muskegon

Clinton

Oceana

Dickinson-Iron

Ontonagon

Eaton

Ottawa

Huron

Saginaw

Ingham

Saint Clair

Jackson

Sanilac

Lapeer

Shiawassee

Lenawee

Tuscola

Luce

Manistee

Wexford-Missaukee

The above County Medical Societies have
certified 1941 membership for all of their 1940

members. Several

more societies are not on

the 100 per cent
delinquent member

roll because of only one

Pontiac General Hospital has started its one hun-
dred thousand dollar building program, which will
add much needed bed space for Pontiac.

H= *

M. M. Jones, M.D., Pontiac, addressed the Macomb
County Medical Society at its meeting of April 22 on
the subject of “The Value of Version in the Manage-
ment of Persistent Posterior Occ put Cases.”

Twenty-five Michigan physicians attended the Seminar
on Psychiatric Problems in connection with the physical
examination of draftees which was held in Chicago on
Mond,ay and Tuesday, May 19 and 20.

^ ^ ^

Graduate course ire electrocardiography for phy-
sicians will be given at Michael Reese Hospital, Chi-
cago by Louis N. Katz, M.D., from August 18 to Aug-
ust 30. Write Michael Reese Hospital, Cardiovascu-
lar Department, 29th and Ellis Avenue, Chicago, for
further information.

>N * *

Alexander M. Campbell, M.D., Grand Rapids, ma-
ternal health consultant of the Michigan Department
of Health in coopeiation vrith the ^Michigan State
Medical Society, has been appointed Chairman of a
State Committee to prepare for the Second American
Congress on Ob 'tetrics and Gynecology, sponsored by
the American Committee on Maternal Welfare.

5|: ^

Selective Service State Headquarters announce that
they will supply speakers on the psychiatric phase of
the physical examination of draftees, as well as other
points in connection with the physical examination, to
any County Medical Society wtiich is interested.
Write Lt. Colonel Harold A. Furlong, Selective Service
State Headquarters, Lansing, Michigan.

^ ^

The Wayne County Medical Society’s Entertainment
Committee has circularized the members of their So-
ciety concerning the interest in a WCMS Cruise over

Bottle of 100
$2.50
Bottle
of 1.000
$22.00

BECOMEX TABLETS (Hartz)

For Vitamin Bi and Vitamin B Complex Deficiency !

This improved Hartz tablet contains
those necessary vitamins to combat
loss of appetite, muscular weakness, pains
in legs and arms, edema, lowered blood
pressure and subnormal temperature, ab-
normalities of the nervous system and
skin, and paralysis agitans due to Vitamin
Br, deficiency. Also, aids in treatment of
pellagra due to lack of Vitamin B Complex.

CONTENTS OF TABLET: Thiamin Hydro-
chloride (Bi), 1 mgm., equivalent to 300
International Units; Riboflavin (B2), 1 mgm.,
equivalent to 400 Bourquin-Sherman Units;
Pyridoxine Hydrochloride (Be), 0.5 mgm.;

Nicotinic Acid, 10 mgm. (clinically demon-
strated to be beneficial in treatment of
trench mouth, x-ray sickness, pruritus
vulvce, delirium tremens, alcoholism, bald-
ness, undulant fever, migraine, and
eczema); Calcium Pantothenate, 2 mgm.
This latter ingredient is a salt of Panto-
thenic Acid which is a filtrate factor from
Vitamin B Complex found in all animal
tissue as a cell constituent It seems to
be necessary for respiration.

DOSAGE: One to three tablets a day,
prescribed by physician.

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June, 1941

Say you saw it in the Journal of the Michigan State Medi :al Society

4S1'

COUNTY AND PERSONAL ACTIVITIES

LABORATORY APPARATUS

Coors Porcelain
Pyrex Glassware
R. & B. Calibrated Ware
Chemical Thermometers
Hydrometers
Sphygmomanometers

J. J. Baker & Co., C. P. Chemicals
Stains and Reagents
Standard Solutions

• BIOLOGIGALS*

Serums Vaccines

Antitoxins Media

Bacterins . Pollens

We are completely equipped and solicit
your inquiry for these lines as well as for
Pharmaceuticals, Chemicals and Supplies,
Surgical Instruments and Dressings.

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A DOCTOR SAYS:

“Knowing that there is such a com-
petent organisation prepared and ready
to protect me against unscrupulous and
designing persons gives me a feeling of
confident assurance that adds greatly
to my peace of mind.”

OF

the week-end of June 20 to June 23. The announce-
ment says : “Music, games, contests, special entertain-
ment. A SEVERE PENALTY FOR ANYONE
TALKING SHOP.’”

Doctor, remember your particular friends, the ex-
hibitors, at your annual convention, when you have
need of equipment, appliances, medical supplies, and
service. Here are more of the firms which helped
make the 1940 Convention such a success :

The Burrows Company, Chicago
The Borden Company, New York
Barry Allergy Laboratory, Inc., Detroit
Bard-Parker Company, Danbury, Connecticut
The Baker Laboratories, Cleveland

The Arlington Chemical Company, Yonkers, New York
A. S. Aloe Company, St. Louis, Missouri
Abbott Laboratories, Chicago.

* * *

A Me^ital Hygietie Conference sponsored by the
Michigan Society for Mental Hygiene and the State
Hospital Commission was held at the Traverse City
State Hospital on May 22-23, 1941. Among the speak-
ers on the program were Governor Murray D. Van
Wagoner, Paul V. Lemkau, M.D., Baltimore; Edgar
C. Yerbury, M.D., Boston; and George S. Stevenson,
M.D., New York.

* * *

C. J. Smyth, M.D., R. H. Freyherg, M.D., and W.
S. Peck, M.D., of Ann Arbor are the authors of >
“Roentgen Therapy for Rheumatic Disease” appear- ;
ing in the Journal of the AM A for May 3, 1941.

“Grafts of Preserved Cartilage in Restorations of
Facial Contour” by Claire L. Straith, M.D., and
Wayne B. Slaughter, M.D., Detroit, also appeared in
the same issue.

* * *

Wm. J. Burns, Executive Secretary of the MSMS,
addressed the House of Delegates of the West Vir-
ginia State Medical Association in Charleston on
May 12-13, on “Michigan Medical Service.” On May
14, Mr. Burns also spoke on “Michigan Medical Serv-
ice” at the 1941 Annual Meeting of the Homeopathic
Medical Society of Michigan held in Grand Rapids.

!(: * ♦

New Officers for 1941-42 of the Michigan Society
of Neurology and Psychiatry were elected at the
annual meeting of the Society on April 24th as fol-
lows: President — P. V. Wagle}', M.D., Pontiac; vice
president — R. W. Waggoner, M.D., Ann Arbor ; sec-
retary-treasurer— David Leach, M.D., Detroit ; coun-
cilors— ^Thomas J. Heldt, M.D., Detroit ; and Martin
H. Hoffmann, M.D., Eloise.

*

Paul V. McNutt, Federal Security Administrator,
invited P. R. Urmston, Bay City, M.D., President of
the Michigan State Medical Society, L. G. Christian,
M.D., Lansing, AMA Delegate ; Russell W. Bunting,
M.D., Ann Arbor ; Emory W. Morris, M.D., Battle
Creek ; L. H. Newburgh, M.D., Ann Arbor ; C. D.
Selby, M.D., Detroit ; and Arthur H. Smith, M.D.,
Detroit, as Michigan delegates to the National Nutri-
tion Conference for Defense which President Roose-
velt called in Washington, May 26-27-28.

*

Malpractice Prevention. — Don’t slight your records.
Keep detailed notes and reports.

Don’t operate without written consent.

Don’t perform certain services (such as fractures)
without x-rays or laboratory diagnosis.

Don’t delegate important duties to unsupervised
nurses and subordinates (such as x-ray treatments,
intravenous injections, etc).

♦ * *

Schistosome dermatitis (Water Itch or Swimmer’s
Itch) is caused by the penetration through the skin
of the larvae of certain species of parasitic worms

Jour. M.S.M.S.

482

Say you saw it in the Journal of the Michigan State Medical Society

COUNTY AND PERSONAL ACTIVITIES

called schistosomes. It results in severe itching and
frequently is the ruination _ of a. pleasant vacation.
Swimmer’s Itch is common in Michigan.

Infection can be avoided in one of the following
ways: (1) Use care in selecting bpches to be used
for swimming; (2) Confine swimming to deep water
on infested beaches; (3) Rub off well with towel be-
fore the water has a chance to dry on the skin. This
will remove most of the larvae before they can pene-
trate. -

The Stream Control Commission of the State of
Michigan has printed an interesting booklet on_ “Water
Itch” which is available by writing the Commission in
the State Office Building, Lansing.

* * *

The Providence Hospital Interne Alumni Associa-
tion held its Annual Spring Clinic on Thursday, May
15. Among the speakers on the one-day program were
Willard O. Thompson, M. D., Chicago; George Crile,
Jr., M.D., Cleveland; Benjamin Levine, M.D., Cleve-
land ; and Rev. Alphonse M. Schwitalla, S. J., St.
Louis, Mo. Golf and Field Day activities were en-
joyed in the afternoon at West Shore Golf and Coun-
try Club at Grosse He, followed in the evening by din-
ner.

4: ♦

The Northern Tri-State Medical Association held
its 1941 meeting at Tiffin, Ohio, on April 9. Officers
for the ensuing year were elected as follows : Lyman
R. Rawles, M.D., Fort Wayne, Indiana, President; E.
Benjamin Gillette, M.D., Toledo, Vice President; F.
R. N. Carter, M.D., South Bend, Indiana, Secretary;
Douglas Donald, M.D., Detroit, Treasurer; and G. O.
Larson, M.D., LaPorte, Indiana, H. E. Randall, M.D.,
Flint, O. P. Klotz, M.D., Findlay, Ohio, Howard H.
Cummings, M.D., Ann Arbor, and Donald Cameron,
M.D., Fort Wayne, Indiana, were elected Counsellors.

* ♦

A. Kuhlman and Company of Detroit recently resur-
rected an antique letter from the Michigan State Med-
ical Society • signed by F. B. Marshall, M.D., of Mus-
kegon, inviting them to participate as an exhibitor
in the M.S.M.S. Annual Meeting of 1912 in Muskegon.
Part of the letter read : “An unusually large attend-
ance is expected at this meeting. A large number of
people from all parts of the United States will be
visiting Muskegon at that time (June), the begin-
ning of the next resort season.”

This interesting document has been in the Kuhlman
files almost three decades !

♦ 4: ♦

The Michigan Pathological Society’s April meet-
ing was held in Flint, Michigan at the Hurley Hos-
pital and Durant Hotel, jointly with the Genesee
County Medical Society. C. W. Colwell, M.D., presi-
dent of the Genesee County Medical Society, and J. A.
Kasper, M.D., president of the Michigan Pathologi-
cal Society, presided. The guest speaker, C. W.

Apflebach, M.D., was introduced by W. H. Marshall,
M.D. Dr. Apflebach’s subject was “Tumors of the
Lungs and Thoracic Cavity,” illustrated by colored
pictures. Cases representing “Tumors of the Res-
piratory System” were presented by Drs. Bond, Bin-
ford, Ahronheim, Backus and Kasper of the Michigan
I Pathological Society.

* * *

Warning against driving when taking sulfanilamide
j is contained in an article appearing in The Journal of
I the AMA issue of May 17. Physicians have ruled
I that airplane pilots must not fly until four days have
, elapsed after they have received any of the sulfona-
mide group. Patients engaged in mechanical work
' of any kind should not take sulfanilamide except
' when relieved of their responsibilities. Patients should

rented ^

in any

contoroeis- aU-qo''^

radon W ^50 pet

jinplante cn »

ms-

MatsVvaUT' .qQ

86c out of each $1,00 gross income
used for members benefit

PHYSiaANS CASUALTY ASSOCIATION
PHYSiaANS HEALTH ASSOCIATION

Hospital, Accident, Sickness

INSURANCE

For ethical practitioners exclusively
(56,000 Policies in Force)

LIBERAL HOSPITAL EXPENSE
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$10.00
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$25.00 weekly indemnity, accident and sickness

For
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$ltl, 000.00 ACCIDENTAL DEATH

$50.00 weekly indemnity, accident and sickness

For
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$75.00 weekly indemnity, aeddent and sickness

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Disability need not be incurred in line of duty — benefits
from the beginning day of disability.

' Send for applications, Doctor, to

400 First National Bank Building Omaha, Nebraska

i June, 1941 483

i

Say you saw it in the Journal of the Michigan State Medical Society

COUNTY AND PERSONAL ACTIVITIES

be cautioned preferably to stay at home and at rest
while taking the drug and not to drive an automo-
bile, make an important decision or sign any papers
while the drug is being administered. Physicians thus
have a definite obligation when prescribing sulfanila-
mide.

1941 EXHIBITORS

Exhibitors at the 1941 Convention of the Michigan
State Medical Society, to be held at the Civic
Auditorium, Grand Rapids, September 17, 18, 19,
1941, include:

Abbott Laboratories North Chicago

Baker Laboratories Cleveland

Bard-Parker Company Danbury, Conn.

Barry Allergy Laboratory Detroit

Rudolph Beaver, Inc Waltham, Mass.

Otto K. Becker Company Huntington, W. Va.

Becton Dickinson & Co Rutherford, N. J.

Bilhuber-Knoll Corp Orange, N. J.

Ernst-Bischoff Co Ivoryton, Conn.

Borden Sales Company New York City

Burroughs-Wellcome Company New York City

Cameron Surgical Specialty Co Chicago

S. H. Camp & Company Jackson, Michigan

Ciba Company, Inc Summit, N. J.

Coca-Cola Company Atlanta, Ga.

Cottrell-Clarke, Inc Detroit

Cream of Wheat Corp Minneapolis

Cutter Laboratories Chicago

R. B. Davis Company Hoboken, N. J.

Davis & Geek, Inc Brooklyn, N. Y.

DePuy Manufacturing Co Warsaw, Indiana

Detroit Creamery Company Detroit

Detroit X-Ray Sales Co Detroit

Dictaphone Sales Corp ..Detroit

Dietene Company Minneapolis

Doho Chemical Corporation New York City

Duke Laboratories Stamford, Conn.

The Ediphone Company Detroit

H. G. Fischer & Company Chicago

C. B. Fleet Company Huntington, W. Va.

General Electric X-Ray Corp Chicago

Gerber Products Company Fremont, Michigan

Hack Shoe Company Detroit

Hanovia Chemical & Mfg. Co Detroi":

J. F. Hartz Company Detroit

H. J. Heinz Company Pittsburgh

Holland-Rantos, Inc New York City

G. A. Ingram Company Detroit

Jones Metabolism Equipment Co Chicago

“The Junket Folks” Little Falls, N. Y.

Kalak Water Co New York

A. Kuhlman & Company Detroit

Professional Economics

An ethical, practical plan for bettering
your income from professional services.

Send card or prescription blank for details.

National Discount & Audit Co.

2114 Book Tower/ Detroit/ Michigan

Representatives in all parts of the United States
and Canada

July 1 — Deadline for Registration
Under Harrison Narcotic Act

Physicians are urged to register now under
the Harrison Narcotic Act in order to avoid
later inconvenience and necessity of paying large
penalties. Failure to register within the time
allowed by law adds a penalty of 25 per cent
to the amount of the annual tax payable at the
time of registration and in addition makes the
physician in default liable to a fine not exceeding
$2,000 or to imprisonment for not exceeding five
years or both. Don’t delay your registration
under this Federal Act.

Tea & Febiger

Lederle Laboratories. . . . . .
Libby, McNeill & Libby..
Liebel-Flarsheim Company

Eli Lilly & Company

J. B. Lippincott Company

. . . . Philadelphia
New York City

.Chicago

Cincinnati

. . . . Indianapolis
. . . . Philadelphia

M. & R. Dietetic Laboratories Columbus, Obio

McKesson Appliance Company Toledo, Ohio

Mead Johnson & Companv ’".vansville, Ind.

Medical Arts Surgical Supply Co Grand Rapids, Michigan

Medical Arts Physicians & Surgeons Supplies Detroit

Medical Case History Bureau New York City

Mellin’s Food Company Boston

The Mennen Company Newark, N. J.

Medical Protective Company Fort Wayne, Ind.

Wm. S. Merrell Company Cincinnati

Michigan Health Service Detroit

C. V. Mosby Company St. Louis

National Live Stock & Meat Board Chicago

Nestle’s Milk Products, Inc New York Cit^

Parke, Davis & Company Detroit

Pelton & Crane Company Detroit

Pet Milk Company St. Louis

Petrolagar Laboratories Chicago

Phillip Morris Company New York City

Picker X-Ray Corporation New York City

Professional Management Battle Creek

Randolph Surgical Supply Co Detroit

Riedel-de Haen, Inc New York City

S.M.A. Corporation Chicago

Sandoz Chemical Works, Inc New York City

W. B. Saunders Company Philadelphia

Sobering Corporation Bloomfield, N. J.

Scientific Sugars Company Columbus, Ind.

Sharp & Dohme Philadelphia

Smith, Kline & French Laboratories Philadelphia

E. R. Squibb & Sons New York City

Frederick Stearns & Company Detroit

U. S. Standard Products Co Woodworth, Wis.

Wall Chemicals Corp Detroit

Westinghouse X-Ray Company Long Island City, N. Y.

White Laboratories Newark, N. J.

Winth?op Chemical Company New York City

John Wyeth & Brothers Philadelphia

Zimmer Manufacturing Company Warsaw, Ind.

The above list of your friends in business is published
for your convenience. When you need reliable medical
supplies or other commodities and service ojfered to
you by these firms, remember they make it possible for
you to enjoy one of the outstanding state medical con-
ventions by their generous support of your annual
meeting. Why not save an order for your exhibitor
friend f

THE MAPLES

A Private Sanitarium for the Treatment of Alcoholism

Registered by the A.M.A.

R.F.D. 3, UMA, OfflO
Phone: High 6447

Located ZYz Miles East of Corner on
U. S. 30 N.

F. P. Dirlam A. H, Nihizer, M.D.

Superintendent Medical Director

Jour. M.S.M.S.

484

Say you saw it in the Journal of the Michigan State Medical Society

COUNTY AND PERSONAL ACTIVITIES

READING NOTICES

HISTORICAL NOTES ON
MEAD'S CEREAL AND PABLUM

Hand in hand with pediatric progress, the introduc-
tion of Mead’s Cereal in 1930 marked a new concept
in the function of cereals in' the child’s dietary. For
150 years before that, since the days of “pap” and
“panada,” there has been no noteworthy improvement
in the nutritive quality of cereals for infant feeding.
Cereals were fed principally for their carbohydrate
content.

The formula of Mead’s Cereal was designed to sup-
plement the baby’s diet in minerals and vitamins, espe-
cially iron and Bi.

That the medical profession has recognized the im-
portance of this contribution is indicated by the fact
that cereal is now included in the baby’s diet as early
as the third or fourth month instead of at the sixth
to twelfth month as was the custom only a decade
or two ago.

In 1933 Mead Johnson & Company went a step
further, improving the Mead’s Cereal mixture by a
special process of cooking, which rendered it easily
tolerated by the infant and at the same time did away
with the need for prolonged cereal cooking in the
home. The result is Pablum, an original product which
offers all of the nutritional qualities of Mead’s Cereal,
plus the convenience of thorough scientific cooking.

Many physicians recognize the pioneer efforts on the
part of Mead Johnson & Company by specifying Mead’s
Cereal and Pablum.

THE TRUE ECONOMY OF DEXTRI-MALTOSE

It is interesting to note that a fair average of the
length of time an infant receives Dextri-Maltose is five
months : That these five months are the most critical

of the baby’s life : That the difference in cost to the

mother between Dextri-Maltose and common sugars is
about $7 for this entire period — a few cents a day :
That, in the end, it costs the motlier less to employ
regular medical attendance for her baby than to attempt
to do her own feeding, which in numerous cases leads
to a seriously sick baby eventually requiring the most
costly medical attendance.

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of the healthiest and most beautiful sections of Michi-
gan. BARGAIN. Address Clyde Smith, 1515 Brook-
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UPPER PENINSULA MEDICAL ASSCOATION
Ironwood, Michigan
July 17 and 18

PROGRAM

Thursday, July 17, 1941

Morning Session

9 ;00 Registration at Grand View Hospital

10:00 Welcome — W. E. Tew, M.D., President

Treatment of Varicose Veins — H. O. McPhett-
ers, M.D., Minneapolis

Practical Application of Vitamin Therapy — C.
Q. Weigand, M.D., Indianapolis

Excretory Urography in the Study of Urologic
Disease — James C. Sargent, M.D., Milwaukee

12:15 Lunch at Grand View Hospital

Afternoon Session

1 :30 Qinical Application of the Sulphonamide Group
of Drugs — Francis D. Murphy, M.D., Mil-
waukee

X-ray in Acute Abdomen — Leo G. Rigler, M.D.,
Minneapolis

Surgical Subject — Chas. W. Mayo, M.D., Roch-
ester, Minn.

Eye Injuries — Ralph Sproule, AI.D., Milwaukee,
President, Wisconsin State Medical Society

Friday, July 18, 1941

Morning Session

10:00 Rectal Diseases — Louis A. Buie, M.D., Roches-
ter, Minn.

Industrial Backache — Paul B. Magnuson, M.D.,
Chicago

Practical Application of Hormone Therapy —
S. C. Freed, M.D., Chicago

Business meeting.

In Lansing

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Chemists to the Medical Profession Oakland Station Pittsburgh, Pa.

Mich. 6-41

June, 1941

Say you saw it in the Journal of the Michigan State Medical Society

485

THE DOCTOR’S LIBRARY

THE DOCTOR’S LIBRARY

Acknowledgment of all hooks received will he made in this
column and this will he deemed hy us as a full compensation
of those sending them. A selection will he made for review,
as expedient.

PROCTOLOGY FOR THE GENERAL PRACTITIONER.
By Frederick C. Smith, M.D., M.Sc. (Med.); F.A.P.S. ;
Formerly Associate in Proctology, Graduate School of Med-
icine, University of Pennsylvania; Fellow, American Proc-
tologic Society; Editor, The Weekly Roster and_ Medical
Digest, Philadelphia County Medical Society; Editor, The
Medical World; Lieutenant Colonel, Medical Reserve Corps,
United States Army. Illustrated with 161 half-tones and line
engravings and S color plates. Second revised edition. Phila-
delphia: F. A. Davis Company, 1941. Price: $4.50.

The title well indicates the scope of this volume. It
describes the diagnosis and care of many pathological
conditions and should be of great help in extending the
physician’s office practice. A number of conditions not
usually associated with proctology are included when
their main connection is with this anatomical area.

4= ♦ *

EMERGENCY SURGERY. By Hamilton Baily, F.R.C.S.
(Eng.) Surgeon, Royal Northern Hospital, London; Surgeon
and Urologist, Essex County Council ; Surgeon, Italian
Hospital ; Consulting Surgeon, Clacton Hospital and the
County Hospital, Chatham; External Examiner in Surgery,
University of Bristol. Fourth edition with 390 illustrations,
of which a large number are in color. A William Wood
Book. Baltimore: The Williams and Wilkins Company, 1940.
Price: $15.00. ‘

This is the fourth edition of a book first published
in 1930. It is typically English, giving great detail with
an overwhelming number of drawings and photographs.
It includes a number of conditions which are not es-
sentially of an emergency nature but its inclusiveness
should be welcome. Many of the figures are in color
which adds to their clarity. The English viewpoint on
some procedures is interesting and of value. For a
complete discussion of emergency surgery it is recom-
mended.

♦ * *

THE AVITAMINOSES. The Chemical, Clinical and Patho
logical Aspects of the Vitamin Deficiency Diseases. By
Walter H. Eddy, Ph.D., Professor of Physiological Chemistry,
Teachers College, Columbia University ; Director, Bureau of
Foods and Sanitation, “Good Housekeeping Magazine” : and
Gilbert Dalldorf, M.D., Pathologist to the Grasslands and
Northern Westchester Hospitals, Westchester County, New
York. Second edition. Baltimore: The Williams & Wilkins
(Company, 1941. Price; $4.50.

Originally published in 1937, this is the second edition
and has been greatly enlarged. For the practitioner
who graduated ten or more years ago this book presents
the necessary information regarding the chemical, physi-
ological and clinical aspects of the vitamin question in a
complete but very readable and easily understandable
manner. The experimental work and its application to
clinical use is splendidly evaluated. It is highly recom-
mended to any physician desiring scientific but practical
information in treating this group of puzzling cases.

^

ROENTGEN INTERPRETATION. By George W. Holmes,
M.D., Roentgenologist to the Massachusetts General Hospital
and Clinical Professor of Roentgenology, Harvard Medical
School; and Howard E. Ruggles, M.D., Late Roentgenologist
to the University of California Hospital and Clinical Professor
of Roentgenology, University of California Medical School.
Sixth edition, thoroughly revised. Illustrated with 246 en-
gravings. Philadelphia: Lea and Febiger, 1941. Price: $5.00.

For the roentgenologist and especially the physician
who does not confine all his time to that specialty this
well-illustrated volume should be of great value. The
authors, who are top ranking roentgenologists, point
out the common errors which are made in interpretation.

the reason for the error, and the manner in which to
avoid the incorrect reading. It is simply written and '
well organized.

♦ ♦ ♦

FIRST AID IN EMERGENCIES. By Eldridge L. Elia son, i
A.B., M.D., Sc.D., F.A.C.S., Professor of Surgery, University^
of Pennsylvania School of Medicine; Professor of Surgery,;
University of Pennsylvania Graduate School of Medicine ;
Surgeon, University of Pennsylvania, Presbyterian, and
Philadelphia General Hospitals. Tenth e^tion completely,
revised and reset. 126 illustrations. Philadelphia : J. B.
Lippincott Company, 1941. Price: $1.75.

This is the tenth edition of the pocket-sized book
first published in 1915. This edition has been entirely
revised and the type reset and many new illustrations
added. The author has avoided quite well the usual
fault of this type of manual ; namely, encouraging too
much home medication and interference. This book
would be a safe textbook for first aid classes.

♦ * ♦

AN INTRODUCTION TO DERMATOLOGY. By Richard L.
Sutton, M.D., Sc.D., LL.D., F.R.S. (Edin.) Emeritus
Professor of Dermatology, University of Kansas School of
Medicine; and Richard L. Sutton, Jr., A.M., M.D., L.R.C.P.
(Edin.) Assistant Professor of Dermatology, University of
Kansas School of Medicine. With 723 illustrations. Fourth
edition. St. Louis: The C. V. Mosby Company, 1941. Price:
$9.00.

This is the fourth edition of this valuable textbook
first published in 1932. In this edition the type has been
reset, and the number of illustrations more than doubled.
Excellent care and judgment have been shown in the
illustrations and the completeness of the volume is
almost unbelievable. Modern treatment is fully described
and every aid is extended the practitioner in diagnosis
and care of his patient. A very complete and well-
arranged bibliography is an additional feature. This
book is recommended to the practitioner who is more
than ordinarily interested in the handling of this group
of cases.

♦ ♦ 4=

FOCUS ON AFRICA. By Richard Upjohn Light, Photographs
by Mary Light. Foreword by Isaiah Bowman, President,
The Johns Hopkins University. New York: American Geo-
graphical Society, 1941. Price : $5.00 ($3.00 to Fellows of the
American Geographical Society).

Doctor Light of Kalamazoo, a well-known brain
surgeon, in company with his wife flew his private plane
over most of Africa in the winter of 1937-’38. The
present economic and military interest in Africa makes
the observations of Doctor Light regarding the political,
agricultural, and economical problems of especial im-
portance and interest to the medical reader. A new
light is shown on this vast continent. The photography
is superb and the selection of subjects well chosen.
The running comment besides being instructive is ex-
ceedingly interesting.

4: * 4!

THE ESSENTIALS OF APPLIED MEDICAL LABORA-
TORY TECHNIC. Details of how to build and conduct an
office or small hospital laboratory at small cost. By J. M.
Feder, M.D., Director of Laboratories and Allergic Service,
Anderson County Hospital, Anderson, S. C. Blood and
Plasma Transfusion. By John Elliott, Sc.D., Pathologist
Rowan General Hospital, Salisbury, N.C. Profusely illustrated.
Two plates in colors. Charlotte, N. C. : Charlotte Medical

Press, 1940.

For the scientifically inclined practitioner in the small
town who envies the clinical laboratory facilities of his
urban colleagues. Here is described the equipping and
management of a small hospital or office laboratory at
a minimum cost. It describes very much in detail how
to make such apparatus as is usually thought prohibitive
in price to the average physician. The book goes on to
describe in great detail and with veiy^ intimate line
drawings and pictures various laboratory' procedures
considered necessary in the modern practice of medicine.

486

Jour. M.S.M.S.

ENZYMOL

A Physiological Surgical Solvent

Prepared Directly From the Fresh Gastric Mucous Membrane

ENZYMOL proves of special service in the treatment of pus cases.

ENZYMOL resolves necrotic tissue, exerts a reparative action, dissipates foul odors;
a physiological, enzymic surface action. It does not invade healthy tissue; does not
damage the skin. It is made ready for use, simply by the addition of water.

These are some notes of clinical application during many years:

Abscess cavities
Antrum operation
Sinus coses
Comeal ulcer

Carbuncle After tooth extraction

Rectal fistula Cleansing mastoid

Diabetic gangrene Middle ear

After removal of tonsils Cervicitis

Originated and Made by

Fairchild Bros. & Foster

New York, N.Y.

Descriptive Literature Gladly Sent on Request.

The Burdick Z-IS Dual Zoalite is a popular pro-
fessional lamp for use on either large or small
areas.

RAY OF COMFORT

Infra-red irradiation is a physiologic sedative and
analgesic.

A Burdick Zoalite will provide comfort for your
patients in such widely diversified conditions as —

Sprains Local inflammations

Strains Arthritis

Coryza

ZOALITE Infra-red Lamps

There is a Zoalite for every type of practice.
Prescription Zoalites are available for home use,
at low rental cost.

THE G. A. INGRAM COMPANY

4444 Woodward Detroit, Michigan

The G. A. INGRAM CO., 4444 Woodward, Detroit, Michigan
Gentlemen: Please send literature on the Z-15 Dual Zoalite.

Dr

Address

City .

fULY, 1941

State

495

Say yon saw it in the Journal of the Michigan State Medical Society

MICHIGAN MEDICAL SERVICE

Again, the medical profession of Michigan can
point with pride to the fact that the label of
“trade” does not apply to the practice of medi-
cine. Through Michigan Medical Service, the
doctors of the state are proving that the pro-
fession has for its prime object the service it can
render to humanity in aiding the citizens of our
state in securing needed surgical and medical
treatment.

In Retrospect

Prior to the organization of Michigan Medical
Service, it was recognized that it was extremely
difficult for citizens of the moderate income
group to provide in their budgets for the payment
of essential medical services required by their
families and themselves. Accordingly, after ex-
haustive studies by the Michigan State Medical
Society, the doctors of Michigan established
Michigan Medical Service as an organization
whereby they offered their services to the people
of Michigan at amounts which would fit into
their budgets, these payments being pooled in a
common fund which would be used to pay the
doctor for his services. This program provided
a means for persons with limited incomes to avail
themselves of medical and surgical service when
necessary. The acceptance of this program is in-
dicated by the state-wide enrollment of over 500
groups, totaling 40,000 workers and their fami-
lies.

Cooperation of Doctors

During the first thirteen months of operation,
the funds received from subscribers were suf-
ficient to pay benefits to doctors for services
rendered in amounts equivalent to prevailing
charges made to persons with moderate incomes
of approximately $1,500.00 tO’ $1,700.00 annually.
This level was maintained, although the volume
of services rendered exceeded that reported in
any study of the amount of medical care re-
quired by groups of people. The increase ap-
plied to both medical and surgical services, the
subscribers requesting treatment for conditions
which had been long neglected and the correction
of which resulted in their increased good health.

In the first four months of this year, the sea-
sonal increase in medical care was emphasized by
a considerable increase in influenza, measles.

MICHIGAN MEDICAL SERVICE REGISTRATION
HONOR ROLL
(As of June 10, 1941)

100 Per cent

Manistee

Mason

Mecosta-0 sceola-Lake
Menominee

90 to 99 Per Cent
Bay-Arenac-Iosco
Calhoim
Gogebic

Grand Traverse-Leelanau-Benzie

Marquette-Alger

Oceana

St. Joseph

80 to 89 Per Cent

Allegan

Barry

Branch

Chippewa-Mackinac

Delta-Schoolcraft

Dickinson-Iron

Eaton

Gratiot-Isabella-Clare

Hillsdale

Houghton-Baraga-Keweenaw

Huron

Ingham

lonia-Montcalm

Kalamazoo

Kent

Lenawee

Livingston

Midland

Muskegon

Newaygo

Northern Michigan

Ontonagon

Ottawa

Saginaw

Tuscola

Wexford-Missaukee

75 to 79 Per Cent

Jackson

Monroe

North Central Counties

Oakland

Wayne

gastro-intestinal disorders, etc. During this peri-
od, there was also an increase in enrollment with
the usual substantial volume of service for the
first months the certificates went into effect. In
view of this situation and in the interests of con-
servative management, payment for services ren-
dered during the month of April was authorized
on a level somewhat lower than that previously
(Continued on Page 498)

496

Jour. M.S.M.S.

NORMAL INFANTS

Whole milk 10 ozs.

Water, boiled 10 ozs.

Karo syrup 2 tbs.

Evaporated milk 6 ozs.

Water, boiled 12 ozs.

Karo syrup 2 tbs.

Powdered milk 5 tbs.

Water, boiled 20 ozs.

Karo syrup 2 tbs.

ALLERGIC INFANTS

Evaporated goat’s milk . . 6 ozs.

Water, boiled 12 ozs.

Karo syrup 2 tbs.

Newborns tolerate a simple formula consisting of 10
ounces of boiled fresh cow’s milk, 8 ounces of sterile
water and 1 ounce of mixed sugar. Added carbo-

I

hydrate in the form of corn syrup is usually better
tolerated than the simple sugars, lactose or sucrose.
At first, about one ounce of the formula will he

Hypoallergic milk . . .

Water, boiled

Karo syrup

Sobee

Water, boiled

Karo syrup

NEUROPATHIC INFANTS

Evaporated milk

Water, boiled

Barley flour

Karo syrup

... 1 tbs.

(cooked ten minutes
imtil thick)

taken at a time although the infant is allowed all he
will take of the three oxmces and the remainder
discarded. The allergic newborn may be given
evaporated cow’s-milk or goat’s-nulk formulas; the
hypertonic newborn thick feeding; the hypotonic
newborn, evaporated or lactic-acid milk formulas.”

Whole milk 12 ozs.

Water, boiled 6 ozs.

25% Lactic acid 2 tsp.

Karo syrup 2 tbs.

2% Lactic-acid milk 18 ozs.

Karo syrup 2 tbs.

2% Lactic-acid milk 18 ozs.

Karo syrup 2 tbs.

'KuGELMASS-/*Newer Nutrition in Pediatric Practice”

THE CHEMICAL COMPOSITION OF KARO
IN GLASS AND IN TINS IS IDENTICAL

Dextrins 37.4%

Maltose 18%

Dextrose 12%

Sucrose 4%

Invert Sugar 3%

Minerals 0.6%

Moisture 25 %

(Karo-:

1 oz. volume. ... 40 grams
120 cals.

1 oz. wt 28 grams

90 cals.

1 teaspoon 20 cals.

1 tablespoon .... 60 cals.
Label)

CORN PRODUCTS SALES COMPANY

17 Battery Place, iVeir Yorh City

July, 1941

Say you saw it in the Journal of the Michigan State Medical Society

497

MICHIGAN MEDICAL SERVICE

(Continued from Page 496)

prevailing. With the seasonal decrease during
the remaining period of the year and Avhen new
groups have passed their first months of service,
it is expected that requests for services will de-
cline to the usual level.

Prompt Payment for Every Service

Due consideration should be given to the fact
that the medical plan has made it possible for
services to be rendered for conditions which the
patient has had for some time, but for which he
has never been able to afford the necessary treat-
ment. In addition, the plan helps eliminate non-
collectible accounts and has lessened the amount
of unremunerated services for patients who
would either be charity cases or would pay only
part of the charge for services.

COUNTY MEDICAL SOCIETY
MEETINGS

Bay-Arenac-Iosco — Wednesday, May 28 — Bay City —
Speaker: Mark F. Osterlin, M.D. Traverse City. Sub-
ject: “Tuberculosis in Children.” Wednesday, June 18
— Bay City — Ladies’ Night.

Berrien — -Wednesday, May 21 — Niles — Speaker: John
T. Reynolds, M.D., Chicago. Subject: “Fractures.”

Calhoun — Tuesday, June 3 — Battle Creek — Speaker:
Pearl Kendrick, M.D., Grand Rapids. Subject: “Re-
cent Research Work in the State Board of Health
Laboratories.”

Dickinson-Iron — Thursday, June 5 — Iron Mountain —
Speaker : William Lange, M.D., Detroit.

Ingham — Tuesday, June 17 — Lansing — Speaker: Carl
Badgley, M.D., Ann Arbor. Subject: “Backache.”

lackson — Tuesday, May 20 — Jackson — Speaker: John
T. Murphy, M.D., Toledo. Subject: “Bone Tumors.”

Kalamazoo — Tuesday, June 17 — Kalamazoo — Joint

meeting with Woman’s Auxiliary.

Oakland — Wednesday, June 4— Rotunda Inn — Speak-
er : Reed Nesbit, M.D., Ann Arbor. Subject: “Chronic
Pyelonephritis.”

St. Clair — Tuesday, May 27 — St. Clair — Speakers :
Herbert H. Hollman, M.D., Detroit and Arthur E.
Schiller, M.D., Detroit. Subject: “New Ideas of
Syphilis and Dermatology.” Friday, June 20 — St.
Clair — Special meeting honoring legislators from St.
Clair County.

St. Joseph — Thursday, June 12 — Klinger Lake Coun-
try Club — Joint Meeting of Medical Society with_ dent-
ists and druggists of the county. Colored movies of
hunting trips were shown by C. E. Boys, M.D. of
Kalamazoo.

Shiawassee — Thursday, June 19 — Owosso — Speaker :
Dr. Charles Kettering, Vice President of General Mo-
tors in Charge of Research, addressed the Society.
He was accompanied by Dr. Walter Simpson, director
of the Kettering Institute and Dr. W. Kendall, the
assistant Director.

Washtenaw — Wednesday, June 25 — Washtenaw

Country Club — ^Joint meeting of the County Dental and
Medical Societies.

Wexford-Missaukee — Thursday, May 29 — Cadillac —
State Society Program with the following speakers :
Paul R. Urmston, M.D., Bay City; Wm. E. Barstow,
M.D., St. Louis; Ed. F. Sladek, M.D., Traverse City;
L. Fernald Foster, M.D., Bay City and Wm. J. Burns,
Lansing.

COUNCIL AND COMMITTEE MEETINGS

1. Wednesday, May 21, 1941, 3 :00 p.m. — Postgradute
Medical Education Committee, University Hospital,
Ann Arbor.

2. Monday, June 9, 1941, 6:15 p.m. — Cancer Commit-
tee, Woman’s League, Ann Arbor.

3. Thursday, June 12, 1941, 3:00 p.m. — Executive
Committee of The Council, Hotel Olds, Lansing.

4. Friday, June 13, 1941, 12:30 p.m. — Representatives
to Joint Committee on Health Education, Michigan
Union, Ann Arbor.

5. Sunday, June 15, 1941, 6:00 p.m. — Syphilis Control
Committee, Hotel Olds, Lansing.

6. Wednesday, June 18, 1941, 6:30 p.m. — Executive
Committee of The Council, Hotel Olds, Lansing.

7. Thursday, June 19, 1941, 6:00 p.m. — Preventive
Medicine Committee, Hotel Olds, Lansing.

8. Friday and Saturday, July 11 and 12, 1941 — The
Council, Mackinac Island.

MICHIGAN PHYSICIANS REGISTERED AT
THE CLEVELAND AMA MEETING
Total— 438

Following is a list of the Michigan physicians who
registered at the Cleveland AMA Convention. Names
are listed in the order in which they appeared in the
Daily Bulletins of the 92nd Annual Session:

Monday: Altshuler, Samuel S., Detroit; Aronstam, Noah E.,
Detroit; Ascher, Meyer S., Detroit.

Backus, G. R., Flint; Bader, Benjamin H., Detroit; Bartlett,
Walter M., Benton Harbor; Beaver, Donald C., Detroit; Beebe,
Irvin J., Morenci; Beeuwkes, Lambertus E., Dearborn; Behen,
Wm. C., Lansing; Bentley, Neil, Detroit; Berman, Harry S.,
Detroit; Birkelo, C. C., Detroit; Bond, Geo. L., Grand Rapids;
Brines, Osborne A., Detroit; Brink, J. Russell, Grand Rapids;
Brisbois, Harold J., Plymouth; Broudo, Philip H., Detroit;
Brunk, A. S., Detroit; Burley, D. H., Almont; Burley, J. H.,
Port Huron; Brush, Brock E., Detroit; Byrnes, A. W., Ft.
Custer.

Caldwell, George H., Kalamazoo ; Campbell, Alexander M.,
Grand Rapids; Carstens, Henry R., Detroit; Christian, L. G.,
Lansing; Christopoulos, D. G., Detroit; Colwell, C. W., Flint;
Curtin, J. H., Flint.

Danforth, Mortimer E.. Detroit; Doyle, F. M., Kalamazoo;
Droock, Victor, Detroit; Duffie, Don H., Central Lake; Dutch-
ess, Charles E., Detroit; Ferguson, Lynn A., Grand Rapids;
Ferrand, L. G., Rockford; Fitzgerald, E. W., Detroit;
Flynn, J. Donald, Grand Rapids; Foster, L. Fernald, Bay
City; Frazer, Mary Margaret, Detroit.

Gould, S. E., Eloise; Green, Mervin E., Ann Arbor; Gruber,
Thomas K., Eloise.

Hagele, Marie A., Lansing; Harkins, Henry N., Detroit;
Hartwell, Shattuck W.. Muskegon; Hasley, Clyde K., Detroit;
Heath, Leonard P., Detroit; High, Anne L., Ann Arbor;
Hirschman, Louis J.. Detroit; Holcomb, J. W., Grand Rapids.
Her, Harris D., Clinton.

Jewell, F. C., Detroit; Johnson, Ralph A., Detroit; Johnstone,
K. T., Grant.

Kallet, Herbert Detroit; Kaump, Dowald H., Detroit;
Kehoe, Henry J., Detroit; Kenyon, Fanny Helen, Detroit;
Keshishian, S. K., Detroit; Kessler, Saba, Bay City; Keyport,
Oaude Roy, Grayling; Kitchen, D. K., Grosse Pointe Park;
Kowalski, V. L., Detroit; Kullman, Harold J., Detroiy

Lam, Conrad R., Detroit; Lash, M. W., Detroit; Levin, Sam-
uel J., Detroit ; Lipkin, Ezra, Detroit ; Lohr, Oliver W.,
Saginaw.

Marcus. Daniel B., Detroit; Martin, R. M., Detroit; McColl,
Clarke M., Detroit; McGregor, Robert, Saginaw; McMillin,
J. H., Monroe; Meader, Fred M., Detroit; Mills, Georgia V.,
Detroit; Morrow, R. J., Lansing; Murray, William A., Detroit.
Naylor, Arthur H., Detroit; Noth, Paul H., Detroit.

Oden, Constantine, Muskegon; Olson, James A., Flint.
Parsons, John P., Grosse Pointe Park; Patmos, Martin, Kala-
mazoo; Panzner, Edward J., Detroit; Peet, Max M.. Ann Ar-
bor; Penberthy, Grover C., Detroit; Perkins, Ralph H., Detroit;

Ratigan, Carl S., Dearborn; Reeder, Frank Elmer, Flint; Reid,
Wesley G., Detroit; Rennell, Leo P., Detroit; Robinson, H. C.,
Grand Rapids; Roth, Paul, Battle Creek; Russell, Ramon de
Alvar ez-Skinner, Ann Arbor;

Schroeder, C. F., Detroit; Selby, C. D., Detroit; Shafer,
Harold C., Bay City; Sharo, A. D., Albion; Sherman, R. New-
ton, Bay City; Shotwell, Carlos W., Detroit; Shurly, Burt R.,
Detroit; Sichler, Harper G., Lansing; Smith, Lillian R., Lan-
sing; Stein, Albert F., Fort Custer; Stevens, Rollin Howard,
Detroit; Straith, Claire L., Detroit; Swenson, H. C., Grand
Rapids.

Tulloch, John, Detroit.

Urmston, Paul R., Bay City.

Vonder Heide, Elmore, Detroit.

Walker, Roger V., Detroit; Walls, Arch, Detroit; Weller,
Charles N., Detroit; Williams, Mildred C., Detroit; Williams,
Robert J., Monroe.

(Continued on Page 500)

498

Jour. M.S.M.S.

palatable ° nutritious
. . , easily assimilated^

X^edeirle’s CeREViITI

CEREViM IS A CEREAL FOOD, formulated by pediatricians
to provide suitable nutritive values for babies and
children. It is distinctly appetizing, easily digested and
non-irritating.

AIDS IN PROMOTING GROWTH: In Comparative clinical
studies* it was shown that Cerevim-fed babies gained
more weight and height than the control babies on their
usual cereal.

HELPFUL IN ANOREXIA AND CONSTIPATION I Ccrevim waS
observed in the study* to stimulate the appetite in
anorexia and relieve constipation in children suffering
from these two common childhood complaints.

FOR INVALIDS AND CONVALESCENTS: Gastro-cntcrologists
prescribe Cerevim for peptic ulcer patients or those in
need of a bland diet of low fibre content. Obstetri-
cians prescribe Cerevim during pregnancy and
lactation; surgeons order it for pre-operative and
post-operative diets.

COMPREHENSIVE FORMULA: Ccrcvim’s comprehen-
sive formula provides proteins, carbohydrates and
fats in a suitable ratio; calcium, phosphorus, iron
and copper in easily assimilated form; and the B
vitamins in generous amounts — all derived from
natural sources only.

Advertised only to the medical projession. Council-Accepted.
Sold only through drug stores.

Pre-cooked and ready for instant use.

Packages; Cerevim is sold in

and 1 lb. packages.

*jOSLiN, c. L. and helms, s. t.. Arch. Ped., 54:533 (Sept.) 1937

LEDERLE LABORATORIES, inc.

30 ROCKEFELLER PLAZA • NEW YORK, N. Y.

July, 1941

Say you saw it in the Journal of the Michigan State Medical Society

499

MICHIGAN PHYSICIANS AT A.M.A. MEETING

MICHIGAN PHYSICIANS AT
CLEVELAND MEETING

(Continued from Page 498)

Tuesday: Balyeat, Gordon W., Grand Rapids; Beaton, Colin,
Detroit; Badgley, Carl E., Ann Arbor; Bernstein, Albert E.,
Detroit; Black, P. S., Detroit; Braley, Alson E., Detroit;
Brasie, Donald R., Flint; Bromme, William, Detroit; Brooks,
Clark D., Detroit; Brown, George Maxwell, Bay City.

Campbell, Lloyd A^ Saginaw; Carey, Benjamin W., Detroit;
Carmichael, E. K., Detroit; Carstensen, Vincent H., Detroit;
Chall, Henry G., Detroit; Cohn, Daniel E., Detroit; Conn,
Raymond W. Detroit; Cope, Henry Erwin, Lansing; Curry,
George Flint.

Doub, Howard P., Detroit; Dowd, Bernard J., Kalamazoo;
Ducey, Edward F., Detroit; DufBe, Don, Central Lake; Dyk-
huizen, Harold D., Muskegon.

Eaton, Robert M.. Grand Rapids ; Elliott, H. B., Hint.
Farris, Jack Matthews, Ann Arbor; Fitts, Ralph L., Grand
Rapids; Foster, Daniel P., Detroit; Freyberg, Richard H., Ann
Arbor.

Graham, Ottis L., Fort Custer; Gregg, Sherman, Kalamazoo;
Gurdjian, E. S., Detroit.

Harm, Winfred, Detroit; Hartgraves, Hallie, Detroit; Harvie,
L. C., Saginaw; Hasty, Earl A., Whittemore; Hauser, I., Je-
rome, Detroit; Heath, Parker, Detroit; Heavner, Lyle E., De-
troit; Hildreth, R. C., Kalamazoo; Horwitz, John B., Detroit;
Hubbell, R. J., Kalamazoo; Huntington, Harry G., Howell.

Jaffar, Donald J., Detroit; Jamieson, R. C. Detroit; Johnson
Richard M., Dearborn.

Kalmbach, Roland E., Lansing; Kane, David M., Sturgis;
Kasper, Joseph A., Detroit; Kelsey, Lee E., Lakeview.

Lang, L. W., Detroit ; Lange, Eugene W., Muskegon ;
Laverty, L. F., Bay City; Lemmon, Charles E., Detroit; Le-
pard, Cecil W., Detroit.

Markey, Joseph P., Saginaw; Maibauer, Fred P., Wyandotte;
McDowell, D. B^ West Branch; McElmurry, N. K., Perry;
McGarry, B. G., Fenton; McGraw, Arthur B., Detroit; McKean,
G. Thomas, Detroit. Miller, Ernest B., Manistee; Millen Nor-
man F., Ann Arbor; Mooney, C. A. Ferndale; Myers, Gordon
B., Detroit.

Noer, R. J., Detroit.

Payne, C. Allen, Grand Rapids.

Ridlon, Joseph R., Detroit; Ripka, Emily L., Lansing.

Roy, Raymond S^ Detroit.

Sagi, Joseph H., Detroit; Selling, Lowell S., Detroit; Selmon,
Bertha L., Battle Creek; Sevensma, E. S., Grand Rapids; Shaf-
fer, Loren W^ Detroit; Sherman, Bessie Boudana, Detroit;
Sladek, E. F., Traverse City; Sladen, Frank J., Detroit; Smyth,
Charley J., Ann Arbor; Smith, Ferris, Grand Rapids; Spoehr,
Eugene L., Ferndale; Steinman, Floyd H,, Flint; Szejda, J. C.,
Detroit.

Top, Franklin H., Detroit; Towsley, Harry A., Ann Arbor;
Turkel, Henry, Detroit.

Waddingtom Joseph E., Detroit; Watson, B. A., Battle Creek;
Watters, F. L., Detroit; Weinburgh, Harry Bennett, Lansing;
Wershow, Max, Detroit; Wetzel, John O., Lansing; Wiersma,
Silas C., Allendale; Wilson, James L., Detroit.

Yntema, Stuart, Saginaw; Zimmerman, I. J., Detroit.

Wednesday : Ames, Chester, Detroit; Anthony, George, Flint;
Atchison, R. M., Northville; Baker, Abel J., Grand Rapids:
Bethell, Frank H., Ann Arbor; Bettison, William L., Grand
Rapids; Bittrich, Norgert M., Detroit; Block, _ N. Berneta,
Lansing; Boccia, James J., Detroit; Branch, Hira E., Flint;
Budson, Daniel, Detroit; Bunting, John W., Alpena; Burr,
Geo. C., Detroit; Burton, D. T., Detroit; Chambers, Myrton
J., Flint; Chandler, Donald, Grand Rapids; Christie, J. W.,
Pontiac; Coller, Frederick A., Ann Arbor; Connors, John J.,
Detroit; Corbett, John J., Detroit; Corneliuson, Goldie B.,
Lansing; Cortopassi, Andre J., Saginaw; Corliss, Grant R.,
Battle Creek.

D’Alcorn, Ernest, Muskegon; De Jong, Russell N., Ann Ar-
bor; De Mol, Richard Grand Rapids; Denison, Louis L., De-
troit; De Vel, Leon, Grand Rapids; Donaldson, Sam W., Ann
Arbor; Doty, Chester A., Detroit; Drolett, Lawrence A., Lan-
sing; IDurham, Robert H., Detroit.

Fast, Ralph B., Kalamazoo; Fauman, D. H., Detroit; Fenton,
Meryl M., Detroit; Fitzgerald, Thomas D., Ann Arbor; Fo-
shee, J. C., Grand Rapids; Fraser, Robert Howard, Battle
Creek.

Gaikema, Everett, Grand Rapids; Gariepy, Louis J., Detroit;
Gay, Harold H., Midland; Gordon,^ Dan M., Detroit; Gordon,
William George, Ann Arbor; Grain, Gerald Orton, Detroit;
Grant, Lee O., Grand Rapids.

Halsted, Lee H., Farmington; Heenan, T. H., Detroit; Her-
kimer Dan R., Lincoln Park; Hershey, Noel J., Niles; Holmes,
Roy Herbert, Muskegon; Holes, J. J., Battle Creek; Holst, John
B., Jackson; Horton, Reece H., Detroit; Hudnutt, O. D., Plain-
well; Hume, T. W. K., Auburn Heights.

Insley, Stanley W., Detroit.

Jackson, Howard C., Ann Arbor; Jaenichen, Robert, Saginaw;
ennings, AJpheus F., Detroit; Johnson, Lester J., Ann Arbor;
ones, Horace C., Detroit; Joyce, Stanley J., Detroit.

Kemler, Walter J., Ecorse; Kemp, Felix J., Pontiac; Ken-
ning, J. C., Detroit; Kilmer, Paul B., Reed City; Kolvoord, T.,
Battle Creek.

Lamberson, Frank A., Detroit; Larson, Bertil T., Pontiac;
Laurin, V. S., Muskegon; Lee, Harry E., Detroit; Leithauser,
D. J., Detroit; Lepley, Fred O., Detroit; Lieffers, Harry, Grand
Rapids; Litzenburger, A. F., Boyne City; Lynch, Vincent A.,
Detroit; Lyons, Richard H., Eloise.

Macinnis, D. P., Pontiac; Mackersie, W. G., Detroit; Mar-
shall, Don, Kalamazoo; Martin, E. G., Detroit; May, Frederick
T.,_ Detroit; Mayer, Willard D., Detroit; McClure, Roy D., De-
troit; McGillicuddy, Oliver B., Lansing; McKinney, Alexander
R., Saginaw; McNeill, Howard H., Pontiac; Meengs, J. E.,
Grand Rapids; Melges, F. S., Battle Creek; Miller, Hazen L.,
Detroit; Miller, J. Duane, Grand R^ids; Miller, M. P., Tren-
ton; Miller, Thomas H., Detroit; Mercer, Frank A., Pontiac;
Meyers, Solomon George, Detroit; Munro, Frederick William,
Grosse Pointe.

Noer, R. J., Detroit; Norton, Richard C., Battle Creek.

O’Donnell, Dayton, Detroit; Ohmart, Galen B., Detroit; Or-
mond, John K., Detroit.

Pfeiffer, Carl Curt, Detroit; Peelen, Matthew, Kalamazoo;
Phillips, James W., Grand Rapids; Prendergast, John L., De-
troit; Pickard, O. W., Detroit; Pino, Ralph H., Detroit; Poos,
Edgar E., Detroit; Pratt, Jean Paul, Detroit; Price, Alvin E.,
Detroit; Price, A. Hazen, Detroit.

Reinsh, Ernest R., Detroit; Rice, Franklyn G., Cassapolis;
Rice, Meshel, Detroit; Robb, Herbert F., Belleville; Robins,
Hugh B., Marshall; Rodgers, William L., Grand Rapids; Ro-
gin, James R., Detroit; Rom, Jack, Detroit; Rozan, J. S., Lan-
sing; Ryerson, Frank L,, Detroit.

Saltonstall, Gilbert B., Charlevoix; Sanford, Hawley. Detroit;
Sawyer, Harold F., Detroit; Schooley, J. P., Detroit; Schroeder,
Chas. Morrison, Ft. Custer; Shafter, Royce R-, Detroit; Shel-
don, John M., Ann Arbor; Shifrin, Peter G., Detroit; Simpson,
C. E., Detroit; Sippola, Geo. W., Detroit; Smith, Henry L.,
Detroit; Smith, W. Joe, Cadillac; Snapp, Carl F., Grand Rap-
ids; Snyder, C. H., Grand Rapids; Somers, Donald C., Detroit;
Stapleton, Jr., William, Detroit; Stein, Lt. A. F., Ft. Custer;
Steinhardt, Milton T., Highland Park ; Steffensen, Wallace H.,
Grand Rapids; Stockwell, Benjamin W., Detroit; Stryker, Homer,
Kalamazoo; Schwartz, Oscar D., Detroit; Szappanyos, Bela T.,
Detroit; Taylor, Nelson, Grosse Pointe; Teifer, Chas. A., Mus-
kegon; Ten Have, Ralph, Grand Haven; Thompson, Alfred A.,
Mt. Clemens; Thompson, Oliver E., Battle Creek.

Wellman, Carl G., Detroit; Weyher. Russell Frank, Detroit;
Whittaker, A. H., Detroit; Williams, C. J., Detroit; Willoughby,
Frances, Travers City; Wilson, James, Detroit; Winfield,
James M., Detroit; Wittenberg, Samson S., Detroit; Wolf-
son, Victor Hugo, Mt. Clemens; Zielinski, Chas. J., Detroit.

Thursday: Adams, James R., Dearborn; Ashley, L. Byron,
Detroit.

Babcock, Myra, Detroit; Ballard, Charles S., Detroit; Beattie,
W. A., Ferndale; Butler, Volney N., Detroit.

Carlson, Harold W., Detroit; Clapp. Henry W.. Grand Rap-
ids; Clark, Emilie Eleanor Arnold, Detroit; Cooksey, W. B.,
Detroit; Cooper, Edmund L., Detroit.

Dillard, M. P., Detroit; Dowdle, Edward, Detroit.

Fennig, Foster A., Marquette; IHaherty, Norman W., River
Rouge; Flaherty, Samuel A., Detroit.

Hansen, Frederick G., Detroit; Hartman, Frank W., Detroit;
Henderson, Harold, Detroit; Honhart, Fr^ L., Detroit; How-
ard, Philip J., Detroit; Howlett, Robert R.,' Caro; Humphrey,
Arthur A., Battle Creek.

Johnston, Chas G., Detroit.

Kahn, Edgar A., Ann Arbor; Keim, Harther L., Detroit;
Fraser, Robert C., Port Huron.

Kinde, M. R., Battle Creek; Kleinman. Shmarya, Detroit;
Kloeppel, Chester S., Detroit; Krieg, Earl G. M., Detroit.

Legalley, Kenneth D., Port Huron; Litzenburger, A. F.,
Boyne City; Long, Edgar C., Monroe.

Mason, P. W., Detroit; Meads, J. B., Jackson; Meade, \\^-
liam Harold, East Lansing; Meinecke, Helmuth A., Detroit;
Metzger, Harry C., Detroit; Meyers, Maurice P., Detroit; Moi-
sides, V. P., Detroit; Murphy, Frank J., Detroit.

Olney, H. E., Detroit.

Pollock, Donald A., Yale;

Reisig, Albert H., Monroe; Richards, C. _J., Durand; Robb,
J. M., Detroit; Robbins, Edward R., Detroit.

The Mary E. Pogue School

For Exceptional Children

DOCTORS: You may continue to super-
vise the treatment anci care of children
you place in our school. Catalogue on
request.

WHEATON, ILLINOIS

85 Geneva Road Telephone Wheaton 66

Jour. M.S.M.S.

500

flo food (except breast milk) is more highly regarded
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milk is definitely desirable — from birth until weaning.

A powdered, modified milk product es-
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made from tuberculin tested cow’s milk
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the butter fat is removed and to which
has been added lactose, vegetable oils
and cod liver oil concentrate.

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BREAST MILK

COLUMBUS, OHIO

July, 1941

Say you saw it in the Journal of the Michigan State Medical Society

501

X- . HALF A CENTURY AGO x-

DIPHTHERIA . . . WHAT SHALL WE j

DO WITH IT?* I

!

W. C. HUNTINGTON, M.D.

Howell

Diphtheria is now understood to be, primarily, a local
affection caused by the action of certain microbes upon
a susceptible surface; and, secondarily, a systemic in-
fection, caused by the absorption of the poisonous prod-
ucts of the primary disease.

The condition necessary for the production of the
disease is the presence of the diphtheritic microbes, in
quantity and activity sufficient to overcome the indi-
vidual’s powers of resistance. This may result from a
powerful colony of microbes acting upon a resistant
surface, or a relatively weak colony acting upon a
susceptible surface ; but, once the disease becomes estab-
lished, the patient with greatest susceptibility suffers
most, providing, the attending circumstances are the
same. Either condition above mentioned would pro-
duce a relatively long period of incubation, with, per-
haps, a prodomal period; for it seems probable that
microbes may exist in the fauces in such quantity that
their products will cause constitutional symptoms before
actual inflammation occurs ; on the other hand, an ex-
traordinary exposure, such as by inoculation or the suck-
ing of a tracheotomy tube, leads to an almost immedaite
attack.

The age of greatest susceptibility is between two and
ten years, with little, if any, relative advantage in
favor of either sex. Susceptibility diminishes from the
latter period to adult life, with the greater immunity
among males after puberty.

Children with light yellow hair, and complexion of
nearly the same hue, seem most susceptible, while
negroes seem to enjoy some immunity against the dis-
ease.

Diphtheria is influenced, in a remarkable degree,
both in its propagation and its effect upon the system,
by atmospheric conditions ; and this fact should be a
prominent element in prognosis and in estimating the
value of treatment. The atmospheric conditions in
which diphtheria shows its greatest virulence, are a
temperature just above the freezing point, with a rare-
fied air loaded with moisture. If, while a diphtheritic
patient is in a critical condition, such weather occurs,
the rarefied air, still further attenuated by moisture,
causes increased respiratory effort, thus increasing the
exhaustion, and deficient oxygenation of blood, with
defective elimination. The devitalized tissues and
moisture feed the microbes to increased action. The
stimulating quality of the blood is impaired, and the
reduced atmospheric pressure invites it into the periph-
eral circulation, and the supply at the nerve centers is
diminished. Instead of sunshine, gloom has settled upon
the earth, and as the patient looks to friends for relief,
he reads anxiety and grief on every countenance. Hope
has gone, cheer has fled, and the patient dies.

The controversy as to whether diphtheria always
results, either directly or indirectly from a previous
case, or whether it may originate de novo, under any
general or special unsanitary conditions, seems settled
in favor of the former ; but unsanitary conditions have

♦Presented at the 26th annual meeting- of the Michigan
State Medical Society at Saginaw in 1891.

502

great influence upon the propagation and virulence of
the disease.

The tendency of opinion in the profession, at the
present time, seems to be to underrate the agency
of the air in conveying diphtheria. I believe that this <
is because the rural districts are too seldom heard
from. Dr. J. Lewis Smith says : ‘^he area of con-
tagiousness of diphtheria is small, extending only a
few feet.” Does the air destroy the diphtheritic germs
within a few feet of the patient? If so, why does it
not do so in infected premises and clothing, where it
remains active for months, or perhaps, years? Or,
does the air, simply by dilution, dessication and reduc-
tion of temperature, so reduce the number and activity
of the germs that would be received by one individual,
that they do not overcome the resistance of persons
of ordinary susceptibility? Do not these germs, carried
by air currents to distances without limit, take root
in congenial soil, propagate and produce sporadic cases?

Three severe epidemics of diphtheria have occurred
in Howell within the limit of my professional experi-
ence. The first one seemed composed entirely of
sporadic cases. They were about equally divided be-
tween village and country, with no apparent possible
connection between them, or any common source of
contagion, save the common air and contagion within
the family. The cases invariably occurred amid unsani-
tary conditions; the weather was of the kind that I
have heretofore described, and a large proportion of
the patients died. With the occurrence of continued
freezing weather, the epidemic subsided.

Several years afterward, one year ago last winter, ]
we had practically a repetition of our former experi- j
ence, excepting that the cases were confined to the I
village. There were, perhaps, evidences of contagion
in some cases. The weather was nearly the same as J
before, much of the t'me. j

The third epidemic occurred last winter. The first I
case occurred in the fall, amid unsanitary conditions,
in a rather isolated portion of the village, where it j
had prevailed the most extensively the year before, t
and probably resulted from the previous epidemic. The •
second case, living near the first one, was a very mild
one of nasal diphtheria. The child was not confined to j
the house and played freely with other children until ^
neighbors took alarm and was called. I found a small j
amount of deposit upon the tonsils, but the anterior I
nares were lined with pseudo-membrane. Many, if not '
all the cases last winter were probably, either directly
or indirectly contagious, and occurred without regard j
to other circumstances or conditions.

The lesson to be drawn from this seems to be that
contaminated air should not be allowed to escape from
the sick room. Diphtheria usually occurs when a fire
can be kept in the room. The effort should be to
create as great a draught as possible and modify the
heat by admitting outside air. This, if possible, should
be received from the same direction as the outside ■
currents, and the result will be to create currents which ,
will prevent the subsidence of germs and convey them,
(Continued on Page 529)

Jour. M.S.M.S. I

■- y

Tlxe JOURNAL

of the Michigan State Medical Society

Issued Monthly Under the Direction of the Council
Volume 40 July, 1941 Number 7

Pre-Operative Preparation
of the Patient

By Ambrose L. Lockwood, D.S.O., M.C., M.D.,
C.M., F.A.C.S., F.R.C.S.(C)

Lockwood Clinic, Toronto, Canada

Ambrose L. Lockwood, M.D.
M.D., McGill University, 1910. Spent
several years in postgraduate work in
New York, London and Germany.
Caught in Berlin at outbreak of the
Great War — escaped and joined the
Royal Army Medical Corps and
served as a surgical specialist with
them five years. Awarded the D.S.O.,
M.C., the Mores Star, ^ and was three
times mentioned in dispatches.
the war he returned to Mayo Clinic,
and was on the Surgical Staff there till
the summer of 1922, when he estab-
lished his own Clinic in Toronto. Has
published numerous treatises in the
field of Thoracic and General Surgery,
and has recently published an exhaus-
tive summary of his experiences in War
Surgery through the British Medical
Journal. Member Canadian Medical Association, Ontario Medi-
cal Association, American Association for the Study of Goiter,
and the Society of Military Surgeons.

■ Specific and thorough pre-operative prepara-
tion for operation is almost as important in
avoiding operative and postoperative complica-
tions and in reducing mortality, as is accurate
diagnosis and painstaking and methodical surgi-
cal technic in skilled hands applied to well-tried
and established surgical procedure. To put it
another way, grave complications and even death
may occur after the very finest executed surgical
procedure because all necessary pre-operative
measures had. not been carried our prior to op-
eration.

Such being the case it becomes equally im-
perative that in establishing the diagnosis, the
operative risk and the possible operative and
postoperative complications be likewise de-
termined, the safest time for operation and the

pre-operative measures that must be carried
out before surgery is to be undertaken. There
must be nothing haphazard in estimating the
risk. Having in mind the risk, the necessary
pre-operative measures must be decided upon
and carried out accurately, methodically and
most thoroughly. Not only must the risk and
pre-operative measures to be carried out be es-
timated for the particular operation, but also
for the alternative procedure that may be
necessary should the one planned not be pos-
sible for one reason or another.

The pre-operative measures to be carried out
vary with the nature of the disease, the compli-
cations, the general condition of the patient, the
gravity and magnitude of the operation to be
carried out and the results to be expected.

Brain surgeiy^ has become so highly specialized
that the pre-operative measures to be instituted
will not be discussed in this presentation.

Thyroid Surgery Preparation

Thyroid surgery is now so widely practised
that the necessary pre-operative preparation
should be the common knowledge of the pro-
fession as a whole. The pre-operative treatment
varies with the type of hyperthyroidism, and the
degree of toxicity.

In 1924, that great physician Henry Plummer
advocated the use of Lugol’s Solution in patients
with exophthalmic goitre. The results were amaz-
ing, and since then Lugol’s solution has been ad-
ministered to such patients in preparation for
operation. Volumes have been written on this
subject, suffice it to point out that when hyper-
thyroidism of the exophthalmic type has been
diagnosed, Lugol’s solution should be administer-
ed if the patient is planning to be operated upon
within the next two or three weeks. The dose

July, 1941

509

PRE-OPERATIVE PREPARATION— LOCKWOOD

varies with the toxicity of the patients. Gen-
erally speaking we plan to give sufficient to have
the maximum effect about the fourteenth day
when surgery should be undertaken.

Patients are started on a dosage of 4 to 8
minims four times a day — increased 2 minims
per dose each day or second day till they are
getting 48 to 80 minims per day. This varies,
of course, with the clinical improvement and
the tolerance of the patient to such a dosage,
and whether or not LugoTs solution has re-
cently been administered. In fact, if patients
have had prolonged treatment vdth LugoTs
solution, which is unwise, we usually stop the
drug entirely. One can predict a striking im-
provement in patients having LugoTs solution
for the first time, but prolonged iodization
clouds the picture, and surgery in such a
patient may be followed by an alarming re-
action.

Frequently it is safer to defer operation in
such patients four to eight weeks to allow the
thyroid to throw off the excess of iodine and to
again become sensitive to iodine. LugoTs solu-
tion should be employed as our most valuable
measure in preparation for operation, but not
for the cure of the disease.

There is some difference of opinion as to
the value of iodine in toxic adenomatous goiters.
We employ it in small doses in such patients
who are extremely toxic, and believe benefit
occurs in those who have a mixed type of gland
— that is — a hyperplasia as well as degenerating
adenomata, and that the benefit is due to sub-
involution that occurs in the hyperplastic tissue.
Patients with a diffuse adenomatosis or with
discrete degenerating adenomata may react badly
to iodization, and instead of improvement, harm
may be done. However, in patients, gravely ill
with a toxic adenomatous goiter, LugoTs solution
should be tried, but the effects must be closely
observed. If they have had prolonged iodization,
surgery must be deferred or an unexpected post-
operative hyperthyroid storm may occur and a
fatality result. Prolonged iodization has, un-
doubtedly, contributed to unexpected postopera-
tive fatalities in patients with toxic adenomatous
goiters.

Generally speaking, however, if employed over
a period of ten to fourteen days the administra-

tion of LugoTs solution is our most valuable
ally in the cure of hyperthyroidism.

Rest in bed, a high carbohydrate diet, sed-
atives and forced fluids are of great value.

Digitalis is rarely indicated or necessary. Oc-
casionally, if the heart is badly decompensated,
it may be wise to try the effect of digitalis, but
it was Plummer’s dictum that digitalis should
not be depended upon to improve the heart suf-
ficiently to warrant thyroidectomy.

Blood transfusions may be necessaiy in the
late stages of hyperthyroidism characterized by
great weight loss, diarrhea, vomiting and de-
lirium, and may turn the tide before LugoTs
solution could become effective. In such patients
sodium iodide intravenously is of great value,
and should be used to hasten the involution
process in the hyperplastic cellular tissue.

Intravenous glucose may also be of value in
such patients if they are greatly dehydrated.

Thyroid extract (desiccated) should be ad-
ministered to patients with so-called chronic
hyperthyroidism characterized by low basal
metabolic readings.

In addition, it is a wise precaution to ad-
minister thyroid extract for six or eight days to
patients past middle age with large adenomatous
goiters which are to be removed for relief of
pressure or because of the fear of malignancy,
particularly if repeated basal metabolic rates are
consistently low. The vital processes of such
patients are thus stepped up, unexpected post-
operative reactions are avoided, and conva-
lescence is more rapid.

In the preparation of extremely toxic pa-
tients for operation the blood iodine level is im-
portant, and we must keep it in mind that damage
to the glycogenic and proteogenic functions of
the liver is the greatest factor to be combatted
if fatalities are to be avoided. That means in
addition to iodine to reduce thyroid activity,
large quantities of fluids, particularly glucose,
are necessary.

In addition to the pre-operative measures
necessary before operative measures are under-
taken, we must determine the advisability of
multiple stage procedures in gravely ill patients
who do not respond rapidly and completely to
the pre-operative measures employed.

510

Jour. M.S.M.S.

PRE-OPERATIVE PREPARATION— LOCKWOOD

Gastric and Duodenal Surgery

The pre-operative measures necessary before
undertaking such surgery consists in overcoming
dehydration, gastric lavage if there is retention,
perhaps combined with the use of dilute hydro-
chloric acid if the stomach acids are low and the
stomach content is foul. Blood transfusion is
necessary to combat profoimd anemia, and es-
pecially if the general resistance of the patient
is low, and a major procedure such as gastric
resection or even gastrectomy may be necessary.
Large amounts of glucose intravenously and cal-
cium chloride intravenously should be given if
there has been prolonged vomiting and the blood
chloride is low.

Vitamin therapy is valuable.

Obstructive Jaundice

The hemorrhagic tendency of jaundiced pa-
tients need not, I am sure, be stressed before this
meeting.

The fact, however, that post-operative fa-
talities due to hemorrhage are still being re-
ported makes further study necessary as to the
cause of hemorrhage, and the additional meas-
ures necessary to avoid such a tragic sequel
to successful operative procedures that in
spite of many technical difficulties are now
well established and sould apart from hemor-
rhage carry little, if any, mortality in ex-
perienced hands.

While it is difficult to demonstrate a close re-
lationship between the tendency to bleed and
the duration of obstructive jaundice, clinically,
bleeding is more common as the period of ob-
struction increases. Tt is more common in ob-
structive jaundice due to malignancy probably
because of hepatic damage. Bleeding is more
common in deeply jaundiced patients yet the
depth of bilirubinemia is not always a controlling
factor in the bleeding. The liver damage in-
creases in prolonged jaundice, but on the other
hand bleeding credited to hepatic disease may
occur in the absence of jaundice as in patients
with biliary fistula and carcinoma of the liver.
All evidence at hand suggests the extent of
damage to the hepatic parenchyma is the most
important factor resulting in hemorrhage in
hepatic disease. The fact that there is no tend-
ency to bleed in patients with hemolytic jaundice

July, 1941

and that spontaneous hemorrhage in patients with
catarrhal jaimdice is rare lends support to the
theory that liver damage accounts for bleeding.

Hepatic insufficiency and renal insufficiency
are associated surgical complications of jaundiced
patients. In addition, damaged liver utilizes car-
bohydrates more freely than other nutrient ma-
terial, and thus large quantities of 10 per cent
glucose is of great value intravenously pre-
operatively. Likewise a high carbohydrate diet
is indicated as well as forced fluids by mouth.
The increase in administration of fluids, orally
and intravenously, improves elimination through
the damaged kidney as well as supporting the
glycogenic function of the liver. Hepatic in-
sufficiently and hemorrhage are the main causes
of death after operative procedures in jaundiced
patients.

The level for serum bilirubin gives the best
indication of the degree of parenchymal injury.
The fact that many deeply jaundiced patients
remain in quite good condition must not be
allowed to give us a false sense of security be-
cause in earlier years it was not uncommon after
operation for relief of obstruction in such pa-
tients to have a grave toxemia develop that
quickly caused an unexpected fatality. This un-
fortunate result is not easy to explain, but may
be due a flood of toxic substances released
from the damaged liver and dilated biliary pas-
sages, into the systemic circulation, causing
“cholemia or hepatic insufficiency” as suggested
by Counsellor and Me Indoe and led Crile to
recommend gradual decompression of the biliary
system in such patients.

It has for centuries been realized that the liver
has a most vital role in maintaining a sense of
well being and there is evidence to suggest that
damaged hepatic tissue in jaundiced patients
does not maintain its important role in the pro-
duction of necessary constituents of the blood
and many investigators such as Rich, MacCallum,
Roenik, Campbell, Rosin and Snell have demon-
strated that the oxygen carrying power of the
blood is not maintained in patients with ob-
structive jaimdice. Anoxemia of the anoxic type
does occur in parenchymal hepatic disease, and
is an additional reason for employing blood trans-
fusion prior to operation. Transfusion not only
increases the hemoglobin and thus the oxygen
carrying power of the blood, but also directly

511

PRE-OPERATIVE PREPARATION— LOCKWOOD

improves the percentage of oxygenation of ar-
terial blood.

Anoxemia associated with prolonged obstruc-
tive jaimdice should be recognized and looked on
as a bad sign. The anoxic anoxia can be relieved
by oxygen inhalation, and the anemic anoxia by
blood transfusion.

Finally in the preparation of the jaundiced
patient for operation in addition to a high car-
bohydrate diet, forced fluids, glucose 10 per cent
intravenously daily, viosterol minims 50 t.i.d.
appears to reduce the bleeding time, vitamin K
and five 10 gr. tablets of ox or pig bile t.i.d. by
mouth is of great value, but blood transfusion is
the most important adjunct, and oxygenation in
those with anoxemia of the anoxic type. Oxalic
acid intravenously may prove of great value in
controlling hemorrhage during and after op-
eration.

The present low mortality in patients operated
upon for relief of obstructed jaundice is due
largely to adequate pre-operative preparation, and
is in direct ratio to the thoroughness with which
it is carried out.

It may not be out of place to point out that
blood transfusion must not be withheld till
the patient is on the operating table or to be
given only postoperatively. It requires some
days for the maximum benefit of transfusion to
become evident in obstructive jaundice. How-
ever, it must also be kept in mind that the
benefit of transfusion is not lasting in jaundic-
ed patients, so that great care must be taken
to operate at the most opportune moment, and
if in doubt additional blood should be given
pre-operatively, and postoperatively as well, in
questionable cases.

It must be emphasized that even if the pro-
thrombin clotting time is within normal limits, the
quantitative level of prothrombin in the blood
may be as low as 40 to 50 per cent of normal,
and that a normal prothrombin clotting time pre-
operatively is not a certain guarantee against
postoperative hemorrhage. The work of Dann,
and of Schmidt and Greaves indicates that the
hemorrhagic tendency is associated with a re-
duction in the prothrombin due to defective ab-
sorption of vitamin K resulting from the absence
of bile in the intestine.

The Ivy bleeding time test is a fairly accurate

indicator of the duration and cause of jaundice
and for determining the tendency to bleed. The
ordinary bleeding time or coagulation time es-
timated from blood withdrawn by puncture of
the finger is not sufficiently accurate to employ
as an indication of the hemorrhagic tendency in
obstructive jaundice.

Surgery of the Large Bowel

Adequate pre-operative treatment has greatly
contributed to reduction in mortality in colon
surgery. Restoring the fluid balance and in-
creasing the carbohydrate intake is important.
Vitamin deficiency must be corrected and blood
transfusions employed when the hemoglobin is
below 70 per cent. Enemas and colonic irriga-
tion should be given to clear out the bowel in
those partially obstructed, and of course patients
totally obstructed must be relieved by cecostomy
before resection is undertaken. Usually four to
eight days are required to prepare patients for
resection, but in the two-stage procedure less
time may be necessary because the preparation of
the patient will continue during the interval of
ten to fifteen days before undertaking resection.
Serums and vaccines that have been employed
to offset peritonitis are of value.

Genito-Urinary Surgery

Pre-operative treatment in such surgery de-
pends upon the general condition of the patient,
as in all cases, but the kidney function must be
determined and every effort made to improve it
prior to surgery — Ringer’s solution, glucose 10
per cent, blood transfusion, viosterol, perhaps
bladder lavage, and forced fluids by mouth may
all be required, and possibly decompression of
the bladder. Perhaps in no field of surgery have
we at hand such accurate laboratory and clinical
data to aid us in carrying out pre-operative treat-
ment. The pleasing reduction of mortality in
genito-urinary surgery has largely been due to
adequate and thorough pre-operative preparation
before surgery is undertaken.

Obesity

Postoperative mortality is very^ definitely in-
creased in certain operations such as gall-bladder
surgery, and particularly after operation for
large ventral and postoperative hemise, by obesity.
Unless operation is urgently necessary, it should
be deferred in obese patients, and they should

512

Jour. M.S.M.S.

PRE-OPERATIVE PREPARATION— LOCKWOOD

be put on a rigid anti-obesity diet and reduced
in weight before surgery is undertaken. This
is particularly important in dealing with large
ventral and postoperative hernise.

Pulmonary Embolus and Thrombosis

Herniotomy for the cure of inguinal hernia is
too often looked on by beginners in surgery as a
simple operation to be undertaken by any novice.
It would be well if the mortality after herniotomy
was more widely recognized. Death from pul-
monary embolus is probably more common after
inguinal herniotomy than after any other opera-
tive procedure. From our experience in the use
of leeches for the relief of phlebitis, I believe it
is a wise precaution to apply leeches the day of
the operation, the third or fourth postoperative
day and at the first sign of an elevation of tem-
perature on the seventh or eighth day or even
later if there is the least suggestion of a phlebitis
developing. I have found leeches of such value
in avoiding and quickly relieving phlebitis when
it has developed that I wish to acknowledge my
thanks to Alton Ochsner for the valuable sug-
gestion. He is most worthily carrying on the
surgical tradition of his renowned and venerated
uncle, the late Albert Ochsner, to whom I have
long been indebted for so many valuable surgical
suggestions. Heparin is of great value in avoid-
ing the development of thrombosis and embolus,
and should be more frequently employed intra-
venously prior to operation in such operations.
Papaverine hydrochloride Yi gr., a vasodilator
given intravenously produces improvement in
the circulation within a few minutes, and may
be valuable just prior to operation and during
operation, as well as postoperatively, in aged
and debilitated patients.

The use of digitalis pre-operatively for patients
with decompensated hearts requiring a surgical
procedure is valuable, but must not be relied on
too much in avoiding a grave postoperative re-
action.

Patients who probably will require oxygenation
postoperatively as in many chest operations
should be accustomed to the oxygen mask or tent
prior to operation. In addition, superoxygena-
tion of the blood prior to such operations is valu-
able during operation.

Every effort must be made to clear up bron-
chitis, troublesome coughs, and nasal and throat
irritation prior to operation, if postoperative

July, 1941

bronchopneumonia and massive collapse is to be
avoided.

Blood Transfusion

Blood transfusion is such a vital life-saving
measure and so frequently resorted to, daily,
throughout the surgical world that any discourse
on pre-operative measures must include careful
consideration of many problems having to do
with the use of blood transfusion. Time will
not permit me to deal at length with the problem
in this address, but I want particularly to point
out that a close study of the reported mortality
directly due to blood transfusion is most alarm-
ing, and indicates that it is a major surgical pro-
cedure not to be lightly recommended, and not
to be carelessly employed.

Hemolytic shock caused during transfusion
must constantly be kept in mind. Gesse
(Leningrad) from replies to 1,700 question-
naires reported a mortality of 52.5 per cent in
200 cases reported. Sighing respiration is per-
haps the earliest warning, followed by a sud-
den change in the general state, excitement,
anxiety, nausea, vertigo, cephalic and lumbar
pain, and a fall in blood pressure. Spasm of
the renal arteries from the poisonous products
of degeneration probably occurs, accounting
for lumbar pain. Glucose must at once be
given intravenously to induce diuresis. Ne-
phrosis is the most common finding at autopsy
of such patients.

Incompatibility between the blood of the donor
and recipient is by far the most common cause
of this grave sequela. Hemolysis due to blood
being stored too long is a factor, as is hemolysis
in recipients who have been febrile for long,
prior to transfusion, and in patients who have
had a profound anemia over a long period.

It is not sufficient to group the donors blood,
but such blood must be carefully cross grouped
with that of the recipient by the hanging-drop
method before being employed.

Using the blood of the same donor a second
time too soon after the first transfusion may
cause a fatality.

A break in technic in collecting and ad-
ministering the blood accounts for a definite
percentage of reactions and death, and must be
carried out with the utmost care to avoid in-
fection.

513

I

PRE-OPERATIVE PREPARATION— LOCKWOOD

Too low a hemoglobin content of the recipient’s
blood may make transfusion dangerous, and
unless transfusion is urgently necessary to save
life, every other means must be taken to improve
the general condition of the patient, and par-
ticularly the hemoglobin before giving blood.
Otherwise, apart from a grave reaction, broncho-
pneumonia or a septic complication may ensue
and cause an unnecessary fatality.

Giving blood too rapidly may cause death.

Unaltered blood or citrated blood may equally
be associated with reactions. The experience of
the Russians in the use of cadaver blood indicates
that such blood is probably safer. Placental
blood carefully collected seems as safe as blood
collected from the vein of a donor.

Properly stored blood, if not held too long a
period, is apparently satisfactory.

Multiple small transfusions given slowly, and
with the most careful surgical care, is safer in
debilitated patients with long standing anemia.

Massive transfusions as employed by Lundy,
who has contributed so much to improvements
in methods of blood transfusion, are at times
necessary, and are life-saving. The drip-method
as employed so successfully at Middlesex Hos-
pital, London, is extremely valuable. Adminis-
tration of Heparin, as developed so expertly by
Murray given intravenously to the donor just
before withdrawing the blood may prove of
great value in avoiding congestion of the blood
and in allowing more time for giving transfusion.

Stored blood serum and powdered blood may
prove of great practical value in offsetting shock
and simplifying transfusion in times of great
stress as under war conditions, but the percentage
of reactions is still too high.

Plasma is an ideal substitute for whole blood.
In traumatic or operative shock, burns or circu-
latory failure, when the red cell count is high,
plasma is indicated instead of whole blood. The
reaction following the use of plasma is much
less than with whole blood and may be given
intramuscularly if it is not possible to give it
intravenously. Outdated bank blood is ideal
as a source of plasma. It can be stored in-
definitely and be easily transported.

Transfusion is contra-indicated in patients in
extremis not due to shock or hemorrhage. On
the other hand, transfusion is specific for acute
hemorrhage and shock, and its use should not
be delayed.

One author reports 35 per cent of reactions in,
100 transfusions and 16.7 per cent of reactions!
in a large group of collected cases. Six of the^
100 patients transfused died as a direct cause of ’
transfusion. ^

Such reactions, while perhaps unduly high, and
the fatalities directly caused by transfusion, must ■
constantly be kept in mind. There must not i
be anything haphazard in selecting the donor,
determining the necessity for transfusion, the
condition of the recipient or the method of col-
lecting and administering the blood.

Careful pre-operative preparation of patients,
their reaction to it, the employment of multiple
stage procedures and operation at the most op-
portune moment are probably the most important
life-saving features of modern surger}', and re-
quire the closest 'cooperation and team-work of
many men working in the closest daily association
if the ultimate reduction in complications and
mortality is to be attained. Surgery has been
made safe for humanity. It still remains, how-
ever, to make humanity safe for surgery. This
means largely earlier diagnosis, greater precision
in pre-operative care, and the select operative
procedure at the proper moment.

References

Gesse, E. : Beitr. z. Klin. Chir., 163: 390-406, 1936.

POLITICALLY CONTROLLED
MEDICINE

“ * * * The threat of politically controlled medicine
can be forever destroyed with unified constructive ac-
tion by the physicians of this country. If every mem-
ber of a County Medical Society in this State would
refuse to hire himself to the Government except as a
part of and with the approval of his Medical Society it
would obviously become impossible for State ^ledicine
to develop. However, he must then be willing and
anxious to meet the Government as a partner in pro-
viding care for the indigent and low income groups.
The governmental agency fulfills its share of the part-
nership by providing the necessary funds, the physician
his share by caring for these individuals at a fraction
of the usual fee. To do this efficiently, all funds from
Federal, State, County and City agencies should be
pooled and devoted directly to the needy sick. * * *” —
From Presidential Address, “Unity in Medicine.” by •
W. Paul Holbrook, M.D., in Southzvestern Medicine, 1
April, 1941. I

514

Jour. M.S.M.S.

CORONARY OCCLUSION— CARTER

Diagnosis of Coronary
Dcclnsion"^

By J. Bailey Carter, M.D,

Chicago, Illinois

J. Bailey Carter, M.D.

B.S.. MS., University of Chicago, M.D.,

Rtish Medical College, 1924. Member of tho
/Attending Staffs of: Augustana and Cook

County Hospitals, Chicago. Assistant Clinical
Professor, Department of Medicine, Rush
Medical College of the University of Chicago.

■ Organic heart disease is widely recognized as
the chief cause of death. Although it is im-
possible to obtain accurate statistics, the in-
crease in death rate appears to be limited to mid-
dle life and old age. Little may be expected in
the way of a reduction in incidence or mortality
from heart disease in later life.^® This will be
due, in part, to the more widespread recognition
of coronar}^ involvement as an important factor
in heart disease, to increased skill in its recogni-
tion, as well as to an actual increase in the num-
ber of cases resulting from a steadily rising pro-
portion of older individuals in our population.
The common impression that advanced coronar}"
disease is fatal results in a feeling of despair.
The situation is by no means hopeless.^^’^” Al-
though the initial mortality is high, a large pro-
portion survive attacks of coronar}' occlusion for
many years. Likewise, let us not neglect pre-
mature coronary disease. It is responsible for
much unnecessary suffering and disability among
persons still in the prime of life. Much has been
accomplished in the control of cancer by govern-
mental, professional and lay organizations. Simi-
lar organizations might be of benefit in educating
the public regarding better health habits, mental
hygiene, the value of moderate exercise and of
sufficient rest. Promotion of periodic health
examinations in middle life would aid materially
in the detection of obesity, hypertension and
diabetes, as well as incipient coronary disease.
The affected individual might then derive the
benefits of proper management and suitable en-
vironmental adjustment.

The prolonged delay in the recognition of the
importance of coronary artery disease seems sur-
prising. Heberden,^^ in 1768, did not suspect

*Delivered before the Berrien County Medical Society, Niles,
Michigan, October 2, 1940.

July, 1941

that such was the basis of angina pectoris, which
has been described®^ as first occurring in 1622.
Although coronary occlusion, correctly diagnosed
during life on May 4, 1876, was first reported by
Hammer^^’^® of St. Louis, it was the classic work
of Herrick,^^ in 1912, that led to its recognition^®
as a distinct clinical entity. During the last
decade few medical problems have been studied
more intensively than disease of the coronary
arteries.^®

Arteriosclerosis has long been recognized as
one of the major pathological states. Its causa-
tion is not understood. Empirical attempts to re-
produce it experimentally have been futile. The
chief cause of interference with the blood supply
to the heart is progressive coronar}" obstruction
resulting from changes essentially arterioscle-
rotic. Areas of softening (atheroma) appear in
the arterial wall, followed by thickening and cal-
cification.®^ The process encroaches on the vessel
lumen. Myocardial ischemia, sufficiently marked
to cause anginal pain, may occur from such nar-
rowing alone. Greater interference with the cor-
onary' circulation results when thrombus forma-
tion about an intimal break, partially or wholly,
occludes one of these narrowed vessels. In most
instances acute coronary' occlusion develops at the
site of such an arteriosclerotic lesion.^® The re-
cent demonstration®® of rich vascular networks
within and around arterioscelerotic plaques was
a significant finding. As a result of this increased
vascularity' of the vessel wall, it is suggested that
the occurrence of hemorrhage or other exuda-
tion within the intima may^ lead to the formation
of thrombus upon the intimal surface, with re-
sultant occlusion of the vessel. It is also sug-
gested that this increased vascularity’ of the ves-
sel wall may^ lessen the untoward effects of occlu-
sion by' supply’ing the basis for a collateral cir-
culation.^-®®’®®’®®’^®

It would appear that, clinically, occlusion in an
otherwise intact coronary circulation would be
most dangerous.®® Sudden death is the striking
feature of coronary embolism, twelve of fourteen
patients having died suddenty.^^ In contrast, in-
farction seldom develops following the rare oc-
clusion due to syphilis, since this is usually
gradual in its development.®

Usually the diagnosis of a ty'pical attack of
coronary’ occlusion can be made with relative
ease. At times it is extremely' difficult or even

515

CORONARY OCCLUSION— CARTER

impossible to arrive at a definite conclusion until
all the facts have been carefully considered.

Fig. 1. (a) Normal electrocardiogram. Chest leads in this
record, as in all others illustrated, were obtained by a simplified
technic modified from Roth.^® After the three standard leads
were recorded the left arm electrode was removed and applied
to the left chest in the fifth interspace at the midclavicular
line; lead wire connections remaining undisturbed. The elec-
trode was held in place by the left fingers of the patient, or an
assistant, lightly applied to the over-lying folded rubber strap.
Lead I and Lead III on the control board were selected in turn;
a Lead IV (CR) and Lead V (inverted CF4) being recorded in
succession. (b) Large Qz, more frequently found in coronary
disease than in any other condition, is here illustrated, along
with tendency to left axis deviation. (c) Flattening of S-T
interval and T wave in all leads, as evidence of coronary
sclerosis, (d) P-R interval of 0.24 second, large Qs and flattened
T2 are significant changes, (e) P-R interval of 0.24 second,
large Qs, QRS complex slurred, QRS interval 0.12 second, and
S-T interval displacement are of significance. (/) Grossly slurred
QRS complex, QRS interval of 0.12 and 0.13 second in dura-
tion, with T wave opposed to the chief deflection of QRS in
each lead, suggests an early bundle branch block of indetermi-
nate type. These changes, along with dropped beats, various
bundle branch lesions, complete heart block, and auricular
fibrillation, are common manifestations of coronary disease.

A carefully elicited history will usually re-
veal significant manifestations which com-
monly occur during the latent period of coron-
ary arteriosclerosis.®^ Undue fatigue, lack of
endurance, nervous irritability, insomnia and
gastro-intestinal disturbances, i.e., palpitation,
belching, epigastric distress or a feeling of ful-
ness and discomfort after meals. Grossly ir-
regular, intermittent or slow pulse may be re-
called. Shortness of breath on exertion,
paroxysmal dyspnea or angina of effort may
have occurred. These are evidence of early
coronary disease; coronary occlusion with in-
farction occurs later, while heart failure finally
develops as the end result of the arterioscle-

rosis. During this latent period electrocardi- I
ography serves as an invaluable check on the .1
clinical examination (Fig 1). It often aids ;
materially in establishing the diagnosis of
coronary disease at a time when proper man- '
agement may be of greatest benefit to the
patient. It should be employed in every case ^
presenting any of the above complaints. It ^
should be used in any case in which, for any I
reason, coronary disease is suspected. j(

The onset of a severe attack of coronary occlu- |
sion is characterized by pain, localized beneath j
the sternum, radiating to the left arm, subscapu- j
lar area, jaw, throat or neck, to the upper abdo- ^
men, and at times to the right chest and arm, ||
It may be constricting or vise-like, burning, bor- C
ing, aching, choking, or simply a sense of sub- j
sternal pressure or distention. It may occur dur-
ing rest or sleep. Typically, it is continuous and |
prolonged. Unlike the pain of angina, it is little |
influenced by activity. Although usually severe ^
the pain may be mild. A colored patient with a 1
severe and fatal attack complained of rats in her ^
chest which gnawed only at night. -

Associated with the pain there is often a sense ;
of prostration or of impending death. Nausea
and vomiting may occur as. initial symptoms, or ,
as the result of morphine administered for the .
control of pain.

Dyspnea as the initial symptom or associated
with pain is nearly always present. The sudden
onset of dyspnea and/or pulmonary edema, in
a middle-aged man, should lead one to suspect
the occurrence of coronary occlusion. Recurrent
chest colds or cough may be significant.

The early picture is frequently that of shock
or peripheral circulatory failure. In some the
picture of heart failure may be outstanding. In
others, there is a combination of the two with
one or the other predominant.^^ It is this vari-
ability in type of circulatory failure that is re-
sponsible for the protean manifestations of
myocardial infarction.

The face is ashen in color. The features, ,
strained and anxious, frequently suggest ex- ’
cruciating pain. The skin is often cold and clam-
my or even wet with perspiration. Cyanosis,
the result of the pulmonary edema, so commonly
present, may be marked from the start or de-
velop later. Moist rales at the base of one or
both lungs may be present.

516

Jour. M.S.M.S.

CORONARY OCCI.USION— CARTER

The sudden fall in blood pressure, in part,
due to peripheral circulatory failure, is likewise,
in part, the result of infarction with resultant
; myocardial insufficiency and directly impaired
cardiac output.^® Experimentally, injury currents
I develop within one or two minutes following oc-
. elusion of even a small coronary branch.®® Con-
traction, in the ischemic area, stops approximate-
ly within one minute.^® Since the infarcted area
J is no longer able to contract and systolic stretch-
i ing occurs, the heart is unable to function
; efficiently. The degree of impairment depends
I on the area and extent of infarction which in
I turn is determined by the site of obstruction.
Since infarction rarely involves the right ventri-
cle the clinical picture, aside from the evidence
of shock, is almost exclusively that of left ven-
tricular failure.

During an attack of coronary occlusion the
blood pressure may be normal or slightly ele-
vated. If recorded soon after an attack the fall
in pressure may be missed unless, repeated read-
ings are taken at proper intervals. In the pres-
ence of an arterial hypertension, where the pre-
vious blood pressure level is unknown, a normal
reading may mislead unless a further drop in
pressure is noted. At times, the electrocardio-
gram may assist by indicating the pre-existing
i hypertension. Whenever coronary occlusion is
I suspected, frequently repeated blood pressure
' determinations is an important diagnostic method
at the command of ever}^ physician.^®

The sudden development of a weak pulse, as-
so'ciated with feeble heart tones, is significant.
The younger the patient the more significant are
these distant heart tones — the more likely are
I they to be due to cardiac weakness alone, rather
' than the result of the emphysema of older in-
' dividuals. The pulse may be rapid, irregular,

; intermittent or slow, the result of tachycardia,
fibrillation, extrasystoles, dropped beats or heart
' block. An inequality in the force of the var-
ious beats may be noted. Pulsus alternans, as
such, is rarely present. Gallop rhythm is com-
mon and is of considerable diagnostic impor-
. tance.® Diminished urinar}^ output is probably
due to the rapid fall in blood pressure, to sweat-
ing and to insufficient intake of fluids. A tran-
sitory or persistent glycosuria may occur. The
, sensorium is usually clear, except for the effects
i of necessa,ry sedation. At times, however, mild

July, 1941

delirium or semi-coma may occur, due to fall in
blood pressure in a hypertensive patient, to pain,

Fig. 2. 5/23/40. Male, aged forty-five, an early QiTi type
of occlusion curve, twelve kours after acute infarction of the
anterior apical portion of the left ventricle. Note that S-Ti
elevation and S-Ts depression, although slight, are present.
Ti shows beginning inversion. The initial po'sitive ventricular
deflection is absent in chest leads with T4, s less positive in
direction. 6/3/40. Eleven days later, S-Ti still elevated, with
definite inversion of Ti and beginning inversion of T2 and
reversal of polarity of T4, 5. 5/31/38. Male, aged fifty-four,

an early Q3T3 type of occlusion curve 8 hours after acute
infarction of the posterior basal portion of the left ventricle.
Note marked S-Ti depression and S-T2, 3 elevation. If a record
is obtained within a few hours after a coronary accident S-T
interval displacement in chest leads is frequently present. This
displacement quickly disappears, usually within a few hours,
at times two tO' three days;^® the chest leads thereafter being of
normal contour. Note that the initial positive ventricular
deflection persists. More commonly, in Q3T3 curves, normal
chest leads are associated with both early and late limb lead
changes; chest leads usually being unaffected by posterior basal
infarctions. 7/14/38. Note large Q3 and deeply inverted
coronary T wave in Leads II and III, with return of chest
leads toward normal

to profound emotional disturbance, or to mor-
phine. Cheyne-Stokes respiration may result
from left ventricular failure, morphine, embolism
or other cause. The frequently undetected
pericardial friction rub may be heard in some
cases. It is of definite assistance in diagnosis.
Embolic phenomena may occur soon after the
attack or later. Pulmonary or cerebral embolism
is more common although infarction of kidney
or spleen may occur. Peripheral gangrene may
occur.® The development of mild congestive
failure is common. The significance of general-
ized edema is serious.

Elevation of temperature with leukocytosis and
increased sedimentation rate are common sequelae
of myocardial infarction. Generally speaking,
the higher the leukocyte count the graver the

517

CORONARY OCCLUSION— CARTER

1

prognosis. Change in sedimentation rate, being
the most sensitive of the three, likewise appears
to be the least dependable.

Fig. 3. 1/10/40. Recorded soon after a mild attack of chest

pain. Male aged sixty-one, withomt previous complaint. In
spite of definite S-Ti elevation and S-Ta depression, it was con-
sidered “normal” and five days later he was allowed to drive
his car 300 miles to Chicago. Another record showed further
evidence of myocardial infarction. Note the large, upright
sharply peaked reciprocal coronary T wave in Leads II and III
of this QiTi type of curve. Although frequently chest leads
simply magnify diagnostic changes already present in limb leads,
they give additional assurance that such changes will not be
overlooked by the inexperienced observer. In a cursory exam-
ination he is less liable to overlook the marked chest lead
change than to miss the corresponding, less marked abnormality
present in the limb leads.

2/18/36. Routine electrocardiogram, male, aged fifty-seven,
without complaint or other significant findings. Definite T2, 3 in-
version. Proper management was urged and refused. On
9/9/39 he returned with dyspnea, recurrent substernal pain
and other evidence of advanced cardiovascular failure. Elec-
trocardiogram was not remarkable, for age, at this time.

1/12/36. Male, aged forty-three, without previous complaint,
had a “cold on chest with cough,” was treated for “flu” by
first M.D., and three weeks later decided he had asthma;
specialist sent him home with a bottle of Digifortis; after the
first dose, collapse, left hemiparesis, and persistent symptoms
and findings of advanced heart failure ensued.

1/25/36. Note minor, but definite, variations from previous
record. Died 2/20/36.

Differential diagnosis involves a consideration
of many conditions'’®’^® listed in Table I. Ade-
quate discussion of this phase of the subject is
beyond the scope of this presentation.

In some cases pain is so severe that angina
seems questionable, yet other readily apparent
evidence of occlusion is absent. A mild fever
or slight leukocytosis is of some help. A peri-
cardial friction rub, if detected, is of definite
assistance. An electrocardiogram may establish
the diagnosis. Should it fail to do so, a single
record should not be accepted as final evidence.
Further graphic study is essential.

At times a severe anginal attack and coronary
occlusion can not be differentiated by ordinary

TABLE I. DIFFERENTIAL DIAGNOSIS OF CORONARY
OCCLUSION

Acute Indigestion
Ptomaine Poisoning
Acute Heart Failure
Cerebral Hemorrhage
Cerebral Thrombosis
Cardiac Arrhythmias
Dissecting Aneurysm
Acute Pericarditis
Cardiac Dilatation
Cardiac Neurosis
Luetic Aortitis
Effort Syndrome
Angina Pectoris
Malingering

Bursitis

Pleurisy

Pneumonia

Pneumothorax

Herpes Zoster

Massive Collapse

Pulmonary Embolism

Carcinoma of Bronchus or Lung

Gall Stones

Peptic Ulcer

Spastic Colon

Tabetic Crisis

Acute Gastritis

Acute Appendicitis

Acute Pancreatitis

Diaphragmatic Hernia

Carcinoma of Stomach or Duodenum

Impending Diabetic Coma

Arthritis of Shoulder Joint
Incarcerated Inguinal Hernia
Arthritis^ — Costochondral Junction
Spondylitis of Cervical or Dorsal Spine
Rupture of Heart, Valve, or Papillary Muscle

methods. Persistence of the pain, for an hour
or more, is highly suggestive. If occlusion is
considered likely, it is a gross error to permit
the patient to return to work or even to become
ambulatory without the benefit of electrocardio-
graphic examination. It is in such an instance
that portable equipment has proven most valu-
able.

When the location of the pain is abdominal,
disease of the gall bladder, stomach, duodenum or
pancreas may be closely simulated. Considera-
tion of blood pressure, sex, habitus, occupation
and heredity of the individual are factors of im-
portance.

There is an important gproup of cases charac- |
terized by absent or insignificant painA® The i
occurrence of painless coronary occlusion, }
with^® or without®® myocardial infarction, is *
becoming more widely recognized. It is to be |

518

Jour. M.S.M.S.

COROX-\RY OCCLUSION— CARTER

expected that the previously reported low in-
cidence of painless,^® as well as atypical
coronary occlusion, will increase with the more

atypical pain equivalents, will bring to light a
surprising number in which an occlusion of a
lesser coronary branch, and occasionally even

Fig. 4. 10/2/39. Male, aged sixty, with attacks of acute dyspnea, interpreted as recurrent

“colds on the chest” during the previous nine months. A curve commonly associated with
arterial hypertension and changes suggestive of coronary occlusion, confirmed by subsequent
r^ords on 11/8/39 and 12/18/39. Diagnosis of generalized arteriosclerosis, arterial hyperten-
sion, hypertensive heart disease with cardiac hypertrophy, left heart failure with coronary in-
sufi&ciency, on the basis of an old coronary occlusion, was made. Absolute bed rest was ad-
vised. Pulse 110. Blood pressure 108 '90, one week later 88/66; has not been above 90/70
since. 10/15/39, embolism of the right lower pulmonary lobe. Up and about since 11/15/39.
Comfortable and symptom-free if activity is limited to two-block walk twice daily. If the
initial record is of this type, diagnosis of occlusion is often difficult. Serial curves are fre-
quently essential. Arterial hypertension and sequelae were determined from the initial record.

3/21/39. Female, aged seventy, illustrates difficulty in the diagnosis of occlusion in hyper-
tensive type of curve.

3/30/40, a subsequent record.

5/26/37. A Q3T3 type of coronary occlusion curve, in a man, aged fifty-four, with estab-
lished arterial hypertension. (4/15/36) A Q3T3 type of coronary occlusion curve with large X
waves in chest leads. (1/28/37) A type of curve commonly associated with lateral infarction. The
characteristic electrocardiogram of lateral infarction reveals^ depression of the S-T inteiwal in
Leads I and II, absence of signs of posterior infarction in Lead III, and a depression of the S-T
interval in Lead IV, with elevation thereof in Lead V, which is tr^ically more marked when
the chest electrode is placed over the fifth interspace in the left midclavicular line than when
it is more medially located. Left axis deviation may or may not be present. Confusion in
interpretation may readily arise; the curve of a lateral infarction not being recognized, for
several reasons. Digitalis effect, at times, may closely simulate this type of record. The graphic
changes of an acute lateral occlusion may rapidly disappear. Confusion results when the
electrocardiogram is not recorded until several days after the accident. The incidence of
auricular fibrillar’on in this group is high. Much confusion results, when, because of the
fibrillation, digitalis is administered before an electrocardiogram has been recorded. The graph
of lateral infarction may closely simulate the typical curve of an established arterial hyper-
tension.

widespread use of electrocardiograms in diag-
nosis. Likewise, there will be a decrease in
the occurrence of “prodromal pain” in coronary
occlusion.® The more widespread use of serial
curves in the study of patients with the minor
complaints of coronary disease, or of mild or

of one of the larger coronary vessels, has oc-
curred. Minor attacks can not be too care-
fully and rigidly studied.

The sudden onset of auricular fibrillation or
flutter, ventricular tachycardia or heart block

July, 1941

519

CORONARY OCCLUSION— CARTER

in a patient without previous cardiac findings,
especially if recently known to have had a normal
electrocardiogram, is highly suggestive of oc-
clusionT°

day to day. It is from this characteristic that
serial curves derive their importance.

The occurrence in the electrocardiogram of
flattening of the S-T interval and T wave, pro-

Fig. 5. 3/20/35. Previous electrocardiogram. 10/4/37, male, aged sixty-one, without ptre-

vious complaint, had severe substernal pain with hemoptysis. 10/5/37, pulse 80 and regular,
blood pressure 116/80, temperature 98.6, left heart border 2 cm. out. No murmur or thrill.
Tones distant. Liver and spleen not felt. No ascites. Noi edema. 10/6/37, blood pressure
106/76, only change. 11/22/37, up and about. Post-occlusion pain in left shoulder. Con-
sidered to be “arthritis.” Dentist removed nine teeth 11/25/37 and seven mo>re 11/27/37,
without relief of pain. Returned to work 12/22/37. Full activity without complaint since.
Note persistence of initial positive ventricular deflection and incomplete reversal of polarity of
the T wave with early return to normal contour in the chest leads of this Ti type of coronary
occlusion curve.

It is possible that, rarely, acute myocardial
infarction may be overlooked in spite of appar-
ently adequate study.

Arteriosclerosis in general is a progressive
lesion and coronary disease is no exception to
the rule. Thrombosis with occlusion, likewise,
reveals this tendency to progression. A mild at-
tack often precedes a major occlusion, or there
may be a series of mild attacks, since thrombosis
of a small branch may extend to the larger ves-
sel from which the branch is derived ; the process
finally involving a much larger vessel than the
initial lesion (Fig. 10). Again the process of
organization within the area of infarction re-
sults in graphic alterations which change from

longed auriculoventricular or intraventricular
conduction and bundle-branch block are common
evidences of coronai*}' sclerosis (Fig. 1).

Parflee^® described a large Q wave in Lead
III, which is the most frequent graphic sign of
chronic coronary disease (Fig. \h, d, e).

Regarding the electrocardiographic changes
following an acute coronary occlusion, Pardee®’’
states, “Not all of these changes are to be found
in every record, but enough of them are present
to give it a characteristic appearance.”

The characteristic elevation or depression of
the S-T interval with reciprocal change in Leads
I and III have been described.®® These typical
alterations following infarction of the left ven-

520

Jour. M.S.^M.S.

CORONARY OCCLUSION— CARTER

tricle, in the vast majority of instances, localize Low voltage commonly develops following
the region involved, which in turn usually in- occlusion/^ Frequently it is of definite diag-
dicates the coronary artery occluded^ (Fig. 2). nostic assistance. A low voltage of electrocardio
As a result of the above patterns the majority gram of a man in his forties, without previous

Fig. 6. Serial curves of Ti type following infarction of anterior apical portion of left ven-
tricle.

of coronary occlusion curves fall into two definite
and distinct topographic groups, which agree
essentially with the specific, muscle bundle, meth-
od of localization.^^ A type which at times
may appear as a QiTj type®^ indicates occlusion
of the left coronary artery with infarction of the
anterior apical portion of the left ventricle. A
Q3T3 type, rarely seen as a Tg type, indicates
obstruction of the right coronary artery with
infarction of the posterior basal portion of the
left ventricle.

Infarction of the lateral wall of the left ven-
tricle, due to occlusion of the left circumflex
artery, gives a less typical pattern®^ (Fig. 4,
1-28-37).

A large P wave occurred in thirty-two (80 per
cent) of forty cases of coronary occlusion
studied ; an amplitude of over 2 mm. being
noted in sixteen (40 per cent) of these
cases. Widening and notching frequently
accompanied this increase in amplitude. The
changes were more frequent in Leads I and II
than in Leads II and III. They were always
present in Lead II (Fig. 3). It is suggested
that these changes in Leads I and II are asso-
ciated with left auricular dilatation. An increase
in amplitude of the auricular sound, as recorded
in stethograms, has been observed following
acute coronary closure.^

Fig. 7. Serial curves of Q3T3 type following posterior basal
infarction.

cardiac complaint, definitely suggests the occur-
rence of a coronary occlusion, even in the absence
of pain or other manifestations thereof, and
should be so considered until proven otherwise
(Fig. 3).

“Attention is drawn’' to a large, upright, sharp-
ly peaked T wave — as diagnostic a feature of the

July, 1941

521

CORONARY OCCLUSION— CARTER

coronary occlusion type of curve as the inverted
cove-shaped T wave of which it is the inverse
image — most commonly found in Leads II and

(Fig. 7). It may well be referred to as the
reciprocal coronary T wave.” As an associated
change it aids in the diagnosis of coronary oc-

Fig. 8. Posterior basal infarction following old anterior apical infarction.

Fig. 9. Posterior basal infarction following old in-
farction of the same Q3T3 type.

Ill of the Ti type of coronary occlusion curve”
(Fig. 3). Basis for this alteration is the long
since recognized reciprocal relationship of Leads
I and III. Such a reciprocal T wave may alsoi
occur in Lead I of a Ts type of electrocardiogram

elusion as does the low voltage curve and large
?2 change.

Much assistance in the electrocardiographic
diagnosis of coronary occlusion has been afforded
by chest leads since their re-introduction®^ in
1932. In many cases they simply magnify diag-
nostic changes already present in the limb leads.
In many instances they are normal in the initial
record and remain so in subsequently recorded
serial curves. This is particularly true of curves
from patients with posterior infarction resulting
from obstruction of the right coronary artery. A
thorough understanding of the significance of the
changes that may occur in the particular chest
lead being used is essential for dependable in-
terpretation. Such knowledge can be acquired
only by prolonged experince with a chest lead
technic known to be dependable (Fig. la). This,
unfortunately, is not true of some of the many
types of chest leads now being recorded. Never-
theless, chest leads are of definte assistance in
some cases, and in certain instances, are essential
for the diagnosis of coronary occlusion. This
may be true in the patient with an old myocardial
infarction. The absent initial positive ventricu-
lar deflection in chest leads,®® at times, may be
the only remaining evidence of an old coronary

Jour. M.S.M.S.

522

CORONARY OCCLUSION— CARTER

occlusion; the limb leads having returned to a evidence of coronary disease.^^ The finding
non-characteristic or even quite normal contour, should be considered a definte indication for
Although not pathognomonic, it is the most de- further study.

Fig. 10. Progressive change following repeated occlusion of lesser coronary branch,
attack 7/1/39. Second attack just before c was recorded.

First

pendable sign, in chest leads, of previous
myocardial infarction.

As in limb leads, S-T interval displacement is
the characteristic chest lead change signifying
the early stages of an infarction. The S-T in-
terval displacement in chest leads, since it fre-
quently persists longer than the early changes
present in the limb leads, may be of assistance in
directing attention to the fact that the occlusion
is of recent occurrence. This S-T interval dis-
placement eventuates in reversal of the cor-
responding T wave, so that, as the changes in
the area of infarction progress, the T wave may
become oppositely directed and remain so in-
definitely.

Reversal of the T wave in chest leads as an
isolated finding, while not diagnostic of coronar}'
occlusion, is a highly significant finding (Fig. 5).
Whereas it commonly occurs in curves from
children with normal hearts,^^ it is uncommonly
seen in the adult electrocardiogram without other

The incidence of an abnormally large T wave
of normal polarity is of sufficiently frequent oc-
currence following a coronary’ occlusion to war-
rant serious consideration®'^ (Fig. 4, 4/15/36).
tyFereas, it not infrequently occurs in otherwise
normal electrocardiograms from patients in
whom no symptoms or findings of heart disease
can be elicited, nevertheless, the finding of a
large T wave, in chest leads, demands further
graphic obsenntion. A huge T wave of reversed
polarity, while less frequent, is more significant.
Although chest leads have not become the “open
sesame”^® in the diagnosis of coronary- occlusion,
nevertheless, they have become indispensable.
Whereas, this is particularly true following
myocardial infarction, it is likewise true, to a
minor degree, in the study of the several less
commonly occurring conditions.^

Perhaps the most valuable recent advance,
from a purely clinical standpoint, has been the

July, 1941

523

CORONARY OCCLUSION— CARTER

more widespread appreciation of the impor-
tance of serial curves^^’ (Figs. 5, 6, 7, 8,

9). Diagnostic changes may be missed if a
single electrocardiogram is recorded too soon
after an acute coronary occlusion.®® Arterial
hypertension, aortic aneurysm, angina pectoris,
congestive failure and digitalis medication, as
well as pulmonary embolism and pericarditis,
may cause confusion.

Whereas, a single record following a coronary
accident may be diagnostic of myocardial infarc-
tion, at times, several curves may be required
before the true situation is revealed. The pro-
gressive electrocardiographic changes following
myocardial infarction, as seen in serial curves,
recorded at properly timed intervals, are
so characteristic, that there are few instances
in which, with the assistance of such curves,
coronary occlusion cannot be diagnosed. “No
other condition has produced the complete typi-
cal picture of acute cardiac infarction.”®®

Again, there is no better way to follow the
progress of the patient who has sustained an
acute coronary occlusion than to observe the
course of the typical graphic changes that result
from the processes of infarct organization.
Symptoms and findings are frequently unde-
pendable and at times misleading. Properly
timed serial records are often of great assistance.

Finally, it should be emphasized that after ade-
quate history, careful examination and essential
instrumental aid, accurate, logical thinking re-
mains the essence of diagnosis in coronary oc-
clusion, as elsewhere in clinical practice.

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524

Jour. M.S.M.S.

CARCINOMA OF THE PROSTATE — ORMOND AND BRUSH

so Willius, F. A.: Life expectancy in coronary thrombosis.
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Carcinoma of the Prostate"^

By John K. Ormond, M.D.
and

Brock Brush, M.D.
Detroit, Michigan

John K. Ormond, M.D.

A. B., Princeton University, 1906. M.D.,

Johns Hopkins Medical School, 1914. Sur-
geon-in-Charge, Division of Urology, Henry
Ford Hospital, Detroit. Member, Michigan
State Medical Society.

Brock E. Brush, M.D.

B. A. and M.D., University of ^ Western On-
tario, 1936. M.S., Wayne University, 1939.

Member of the staff of Henry Ford Hospital.

■ This report is the result of a review of one

hundred and twenty-five cases of carcinoma
of the prostate. Of course, it is impossible to
present anything new on the subject of pro static
carcinoma, but an occasional review of the old
hackneyed subjects is valuable.

There is only one other large group of pa-
tients which is so trying coming under the care
of the urologist, namely, the group with cancer
of the bladder. In both groups, the victim of
the disease is likely to consult the physician late
in its course, at a stage when palliation may be
all that can be expected. This is usually more
true of the victims of prostatic carcinoma than
of bladder carcinoma.

This report contains cases treated in almost
every known way, by masterly inactivity, radium,
x-ray, suprapubic prostatectomy, perineal pros-

*From the Division of Urology, Henry Ford Hospital, Detroit,
Michigan. Read before the Detroit Branch of the American
Urological Association, April, 1940.

July, 1941

tatectomy, resection, cystostomy, and combina-
tions of these methods ; so that it is possible to
compare the results of different forms of treat-
ment.

Of course, in comparing results there are
other factors to be considered besides the method
of treatment ; among which are ( 1 ) the patient’s
chronological and physical age, (2) the extent
of the process when discovered, and (3) the site
of the origin of the growth.

That the chronological age and the physical age
do not always correspond is, of course, well
known. Some men at fifty are as old as others
at seventy, and the hale and active octogenerian
is no stranger to any of us. In general, it can
be said that the younger the patient the more
rapidly does a cancer develop. Many cases in
the older group grow and metastasize so slowly
that local obstruction is the chief inconvenience.
Some of these do very well so long as urinary
obstruction does not appear, or if that obstruc-
tion can be removed. Metastases and extension
through the pelvis may be postponed for long
periods and the patient live in comparative com-
fort. Such patients, carrying on very well with
a cystostomy or following resection, are not es-
pecially rare. In some cases, where there is both
hypertrophy and malignant disease, removal of
the hypertrophied masses may be indicated. An
example is one man in whom the diagnosis was
made in 1928 ; suprapubic prostatectomy was car-
ried out in 1931, resection has been done twice
since, and he now at the age of 85 carries on
vigorously, is in active business and is a factor
to be considered in everything in which he is in-
terested, In this instance the tissue removed at
all three operations was definitely carcinoma, and
rectal examination still shows a large stony hard
mass in the prostatic region. Another man, a
physician in his seventies, came in each year, for
some years, for examination; no operation was
done and there seemed to be no progress in the
condition. He knew of the presence of the car-
cinoma and came in merely for a check-over.

In contrast are the patients in the younger
group in whom extension and metastasis are very
rapid ; who rapidly go from bad to worse ; whose
discomfort and deterioration nothing can control,
obstruction recurring rapidly , and pain in back
and thighs being intractable; and whose end is
welcomed by patient, relatives and physician.

Of course, the largest group comes in between

525

CARCINOMA OF THE PROSTATE— ORMOND AND BRUSH

these two, and here the variation in physical age
seems to play the greatest role. Some are slow
in their course, some rapid. The great majority,
however, are not seen until the condition is fair-
ly well advanced, and the previous duration of
the disease may be difficult to estimate. In the
series covered by this review the average age
of the patients was 64.9 years, the youngest be-
ing 40, and the oldest 93.

The site of origin apparently may be in any
portion of the gland. It used to be thought that
practically all started in the posterior lobe, but
of recent years more intensive pathological in-
vestigation has shown more of them originating
in the lateral lobes than was previously thought.
However, it is still generally accepted that the
usual point of origin is in the posterior lobe.

Spread of the disease is in three ways : First,
by direct extension to the seminal vesicles and
through the pelvis. Second, by way of the lym-
phatics, to the pelvic and abdominal lymph
glands, and third, by way of the blood, chiefly to
bone, and this may precede lymphatic spread.
The recent work of Batson has thrown a great
light on the distribution of metastases by way
of the viens. Apparently almost three-quarters
of all metastases are to bone ; oftenest to the pel-
vis, spine and femur, and less often to the ribs.
The region of the sacro-iliac joints seem to be the
first place to look for the chalky appearance of
metastasis. The chief source of confusion is the
relatively rare Paget’s disease, and here the con-
figuration of the interior pelvic outline may be of
aid, or x-rays of the skull may solve the prob-
lem, for in Paget’s the skull is usually thickened.
This differentiation may be of importance, for
occasionally prostatic carcinoma may metastasize
before rectal examination is suggestive, especial-
ly in the rare cases of soft carcinoma.

Undoubtedly, it is the most frequent carcinoma
seen in the male. In 1939 these were reported
in the Journal of the American Medical Associa-
tion the death of 3,879 physicians, including
116 women. Among these deaths, 357 were due
to cancer and of those due to cancer, the largest
number — 62 — ^were due to carcinoma of the pros-
tate.

Diagnosis is usually made by rectal examina-
tion, occasionally by the demonstration of typical
bone metastases in the x-rays and in accustomed
and skilled hands, by the use of a needle thrust
through the perineum. This latter method re-

quires an operator and (even more important)
a pathologist of great experience in the method.
It was not used in any of the cases considered
in this report.

Differential diagnosis is from tuberculosis,
stone, and occasionally chronic inflammation.
Usually there is no difficulty; the stony hard-
ness and nodular character of typical carci-
noma are unmistakable, though there may be
confusion in early cases. Rarely seen are cases
of tuberculosis in which there is much reason
for error. Stone is usually comparatively
easily recognized, and in case of doubt the
x-ray will clear the diagnosis immediately. In
a very few cases chronic inflammation gives
rise to confusion, but, fortunately, most of
these are in cases in which delay makes no
difference and no harm results from waiting
unitl the later course clears the diagnosis.
The extent of the process when first seen is
usually so great that if it be carcinoma it is
beyond hope of cure. Occasionally in younger
men, however, small nodules may be a source
of anxiety unless they disappear under a short
course of treatment.

Treatment

Lastly comes the black subject of treatment.
Treatment in the vast majority of patients is
unavailing so far as cure is concerned, and not
too satisfactory so far as amelioration is con-
cerned. In this series are cases treated by ra-
dium, deep x-ray, suprapubic prostatectomy, con-
servative perineal prostatectomy, radical perineal
prostatectomy, transurethral resection and cystos-
tomy.

Only seven patients were treated by radium
and in only one did any benefit seem to result,
and even he developed so much scar that the
years he lived thereafter were made fairly mis-
erable by the necessity for frequent dilatations
under general anesthesia. He finally died of
uremia.

Deep x-ray therapy was used in thirty- four
cases and seemed to be valuable treatment for the
pain produced by bony mestastases, but caused
no particular retardation of the progress of the
disease. Suprapubic prostatectomy in most cases
makes matters worse, though where there is, in
addition, much ordinary adenomatomous h)'^per-
trophy it may be done with benefit. Conserva-

526

Jour. M.S.M.S.

CARCINOMA OF THE PROSTATE— ORMOND AND BRUSH

tive perineal prostatectomy is probably better
than suprapubic, but not much better.

Occasional cures result from prostatectomy in
cases in which the presence of carcinoma was not
suspected until the tissue was examined micro-
scopically; and this fact may constitute an ob-
jection to resection for hypertrophy unless an es-
sentially complete prostatectomy is done tran-
urethrally.

Suprapubic prostatectomy was done in eighteen
cases, in eleven of which the diagnosis was not
made before operation. The average length of
life of the seven known to have carcinoma be-
fore operation was twenty-two months ; of the
other eleven it was four years, one living six
years and another still living after seven years.

Resection to remedy obstruction is valuable,
though it does nothing to hinder the progress of
the disease, and recurrence of the growth may
make repeated resections necessary. Resection
was used in twelve cases known to have cancer,
the average duration of life afterward being
fifteen months. Of course, these were advanced
cases before operation. Carcinoma was found
in the tissue removed by resection for benign
hypertrophy in four instances. One lived three
years, another two and one-half years, one is
alive and well after one year, and the other com-
mitted suicide after two and one-half years.

Cystostomy requires only brief consideration.
In some cases it gives great comfort and as a
palliative may be preferable to resection, par-
ticularly where urinary infection is great. It
was done in only four of the cases considered
here. There is only one instance of chorodotomy
and none of alcoholic spinal injection.

The final method of treatment is radical peri-
neal prostatectomy as advocated by Hugh Young
and George Smith, who have had a rather large
experience with it. This consists in the removal,
perineally, of the whole prostate, including its
capsule and all, or most of the seminal vesicles,
with suture of the neck of the bladder to the
membraneous urethra. This is applicable only to
early cases before the disease has spread beyond
the prostatic capsule, though George Smith ad-
vocates its use in some more advanced and bor-
derline cases where he finds that the comfort and
life of the patient are both prolonged. This
method was used seven times with the following
results :

One patient had good control of his urine and

lived eight years, dying then of pneumonia.

One is alive and well after three and one-half
years, with fairly good urinary control, losing a
few drops if he strains or coughs.

One is alive and well after two and one-half
years, completely incontinent.

Two died of metastases after a few months.

Two were operated on recently. Both of these
are completely continent, and one states that
erections occasionally occur.

Conclusion

This paper may be concluded with a statement
of our present attitude toward patients with
carcinoma of the prostate:

1. If demonstrable metastases are present
when first seen (40 per cent in this series), only
palliation for obstruction and pain is possible.

2. In the other cases, where the diagnosis is
unmistakable, in general nothing should be done
until obstruction requires treatment or pain ap-
pears. For obstruction, resection seems the
method of choice. However, particularly in some
of the younger group, the use of radon seeds
may be considered.

3. In the early cases the radical operation
should be considered, especially in the younger
patients. In most of these cases, the diagnosis
must be in doubt until made by frozen section
at the time of operation. Undoubtedly the field
for this operation will be increased by more fre-
quent early recognition of the disease. This
means that stress must be laid on the importance
of intelligent rectal examinations. Until rectal
examinations are made more frequently and reg-
ularly as a part of a complete physical examina-
tion, and before symptoms appear, early cases
will be rarely found. In the series reported here
only seven cases were considered suitable for
this operation. Of the last two, one was dis-
covered incidentally in a man who came to the
hospital for a routine check-up ; the other, a
man of forty-nine, was referred by one of the
graduates of the hospital who had discovered it
in the course of a general physical examination.
Any firm nodule in the prostate of a man of fifty
or over should rouse suspicion, and these nodules
seem more likely to be found near the lower
pole and near the mid-line. It is certain that
the percentage of cures will not increase until
this disease is more often recognized early
enough to warrant radical removal.

July, 1941

527

ARTHRITIS— YOTT

Arthritis

A Contra-indication for Typhoid
Vaccine Fever Therapy

By William J. Yott, M.D.

Detroit, Michigan

William J. Yott, M.D.

B.S., University of Detroit, 1^31. B.M.,

Wayne University College o-f Medicine, 19S4-
M.D., Wayne University College of Med cine,

1935. Attending Staff of Alexander Blain
Hospital, Detroit. Gynecological and Obstetri-
cal Staff, St. Mary’s Hospital, Detroit. Jti-
nior Fellow of the American College of Sur-
geons. Member of the Wayne County M"d^-
cal Society and the Michigan State Medical
Society.

■ Accepted methods in the treatment of ar-
thritis vary greatly, but one which is most
universally recommended is treatment with
foreign protein or fever therapy. Some au-
thors specifically recommend Typhoid Vaccine
Fever Therapy (especially in the active febrile
type of case) and report having given thou-
sands of them without any untoward results.
The usual first dose should be 25,000,000 in-
travenously, gradually increasing the size in
subsequent doses, so as to obtain a good chill
and febrile reaction with each injection.

Cinchophen or atophan is well known as
a drug used promiscuously by a great number
of people who do not appreciate the dangers
involved. In four books on materia medica
only one mentioned that on prolonged admin-
istration hepatitis might occur and in none
of the others was any mention of toxicity.
In my experience I have found that druggists
are very prone to recommend it, as are laymen.

Two years ago I encountered a case which
impressed me with the possible danger of ad-
ministering typhoid vaccine to a patient who
had previously taken cinchophen. In no refer-
ence have I found the use of typhoid vaccine
contra-indicated after cinchophen therapy al-
though it is mentioned that typhoid vaccine
should not be used in patients with chronic
cardiac disease, in elderly patients, or those
who give a history of tuberculosis.

A case report will help to clarify the point
I am trying to make.

The patient was a well-nourished, white female, aged
fifty-six, resting fairly comfortably in bed when first
seen in the home. She was complaining of low back
pain and pain in her extremities with swelling and

tenderness in the phalangeal and metacarpo-phalangeal
joints for the past six weeks with no noted tempera- I
ture. The only history of previous treatment was 1
that of having seen a chiropractor a few times with no 1
beneficial results. There was no history of any medi-
cation and it was recommended that she enter the hos-
pital for examination and observation.

She was admitted to the hospital, January 22, 1938,
complaining of pain in hands, feet, legs and back for
the past six weeks. About two weeks previously the
patient had her first attack of pain in back, starting i
in both lumbar regions and radiating down the thighs.
There was some headache associated with it and vom-
iting, but no other symptoms.

Past History. — Negative except for slight swelling *
of ankles at night. Appetite good, no dietary dyscrasies, i
constipation, diarrhea or other intestinal complaints.

She had diphtheria as a child and an appendectomy
at 51.

I

Laboratory examination (1/24/38). — Negative uri-
nalysis and Kline test. Hb. 75 per cent; R.B.C. 4,-
570,000; C.I. 9.5; W.B.C. 4,700 (58% P. Neut., 2%
Baso., 38% Lympho., and 2% Trans.).

There was no positive findings on examination ex-
cept for a low right rectus scar with good healing,
slight dehydration from vomiting, and stiffness, ten-
derness, redness, and swelling of all the joints of •
the extremities.

X-ray report. — Pelvic and lumbar spines free of any
pathology. The extremities showed an early hyper-
trophic arthritis.

At no time during the patient’s stay in the hospital
under observation did her temperature rise above 99.
The third day when her vomiting had subsided and
she felt much better, we gave her 10,000,000 typhoid
intravenously with a good reaction and sent her home
on the following day greatly improved on a purine-
free diet, reduced iron, and a sedative.

On January 28, while still at home, and having had
such good results from the first injection of typhoid
vaccine, we gave her a second intravenous injection
of 25,000,000 typhoid, at her request. This was fol-
lowed on the next day by nausea and vomiting, and
on the third day she developed a slight icterus which
has gradually progressed until on February 16 she
was again sent to the hospital. Since her last injec-
tion she had been symptom-free with no pain except
for beginning pain in the joints of her fingers. The
jaimdice had gradually increased but at no time were
there chills or fever or abdominal pain.

Two days before readmittance to the hospital she
started to vomit and noticed that her stools were tarry
in color. Vomitus contained “coffee ground” appear-
ing material. Patient had been on a high carbohydrate
diet since developing icterus.

Physical examination this time revealed an icteric
patient with no petechise, sclerae were very icteric, and
the liver was difficult to percuss out. B.P. 120/60;
pulse 120 ; temperature 101 ; urinalysis 4 plus bile,

3 plus alb., many R.B.C. and W.B.C., casts. Hb. 78
per cent; urea 26.1 mgs.; dextrose 153 mgs. Stool:
occult blood ^nd urobilinogen present. Gastric con-

528

Jour. M.S.M.S.

MASSIVE ARSENOTHERAPY— SHAFFER

tents : occult blood, 10 per cent free HCl., 20 per
cent total acid, no lactic acid. Icterus Index 100.

Condition gradually became worse so that on
2/18/38 she became comatose and expired in the after-
noon.

Gross summary at autopsy was an acute yellow
atrophy of the liver with intense jaundice and subse-
quent diffuse hemorrhage from the gastro-intestinal
tract.

As has been stated, there was no history ob-
tainable of her having taken cinchophen and it
was impossible, due to the fact that the drug
had been prescribed by a pharmacist and not
by a physician, to make the family admit that
she had taken this drug until the husband
came in at a later date, and, when pointedly
asked if his wife had ever taken cinchophen,
admitted that she had taken small doses for
approximately six weeks before I was called.

Conclusions

1. Typhoid vaccine given intravenously to
produce fever is contra-indicated in the pres-
ence of liver damage.

2. Cinchophen therapy in the presence of
suspected liver damage is hazardous.

3. Cinchophen intoxication should be care-
fully watched for by the patient and physician
during therapy.

4. Before any fever therapy, it is well to
specifically question the patient as to having
taken cinchophen or any kind of treatment
which may have caused liver damage.

DIPHTHERIA: WHAT SHALL WE
DO WITH IT?

(Continued from Page 502)

either into the stove or within cremating distance of
its outer surface.

Dr. J. Lewis Smith reports excellent disinfectant re-
sults from the following:

“Rx Acidi carbolici, 01. eucalypti, aa oz. 1 ; spt’s
terebinthinse, oz. 8. Mix. Add two tablespoonfuls to
one quart of water in a shallow pan, with a broad sur-
face, and maintain it in a constant state of simmering
in the room occupied by the patient.”

It would certainly be desirable if the air in the room
could be kept constantly disinfected, as Dr. Jacobi
states that convalescents are sometimes re-infected from
the room which they have themselves infected; besides
which, experience has proven the above remedies to
be efficient in the direct treatment of the disease. * * ♦

Massive Arsenotherapy
In Early Syphilis’'

By Loren W. Shaffer, M.D.

Detroit, Michigan

Loren W. Shaffer, M.D.

B.S., University of Michigan, 1915. M.D.
University of Michigan. 1917. Professor of
Dermatology and Syphilology, Wayne Univer-
sip Medical School. Director, Social Hy-
mene Division, Detroit Department of Health.

Member, Michigan State Medical Society.

■ The five-day ultra-intensive treatment for
early syphilis has aroused great interest. If
early (primary or secondary) syphilis can be
cured in five days with intensive treatment,
the control of syphilis will be revolutionized.
This treatment, if further observation proves
that it is both safe and effective, offers the
greatest advance in the therapy of syphilis
since Ehrlich’s introduction of salvarsan. The
two main problems in syphilis control are the
finding of early cases, and the holding of these
cases to adequate continuous treatment for
eighteen to twenty-four months. If treatment
can be completed in five days, the almost in-
surmountable problem of holding such cases to
adequate treatment will be solved.

The suggestion that very large doses of
arsenicals might be given with safety in the
treatment of syphilis was first made by Louis
Chargin,^ syphilologist to the Mount Sinai
Hospital and the New York City Department
of Health. It was based on the observation
of Drs. Hirshfield, Hyman and Wanger,^ show-
ing that “speed-shock” could be prevented by
very slow intravenous administration (60-90
drops per minute). Such administration also
permitted the introduction of remarkably large
amounts of highly toxic substances with com-
plete impunity.® With the authorization of
the trustees of the Mount Sinai Hospital, such
work with arsphenamines was begun on Dr.
Baehr’s service in 1933.

In the first series, twenty-five patients with
early syphilis were treated by Drs. Chargin,
Leifer and Hyman.^ Four to 4.5 gms. of neo-
arsphenamine was administered by continuous
intravenous drip in five days; 87 per cent of

*From the Social Hygiene Division _ of the Detroit Depart-
ment of Health and the Wayne University Medical School.
Presented at the Secretary’s Conference, Michigan State Medi-
cal Society, Lansing, Michigan, January 19, 1941.

July, 1941

529

MASSIVE ARSENOTHERAPY— SHAFFER

these cases were cured, as far as it was pos-
sible to determine, at the end of five years.
No additional cases were treated until 1937,
when this method of treatment was resumed
under a committee including Drs. Rice, Rosen-
thal, Mahoney, Clarke, Palmer, Dubois, and
Baehr. Eighty-six cases of primary and sec-
ondary syphilis were treated with neoars-
phenamine by the method used in the first
group. A report of these cases was made be-
fore the American Medical Association in
1939, by Hyman, Chargin, Rice and Leifer.®
Two-year cures were reported in 91 per cent
of these cases. The incidence of toxic reac-
tions was high, especially with neuritis. The
only treatment fatality in the two series (111
patients) was due to hemorrhagic encephalitis,
and further use of neoarsphenamine was dis-
continued in the fall of 1938. Arsenoxide (Ma-
pharsen) was substituted.

When Mapharsen was first tried there was
no experience available with its use in larger
dosage. T^e usual recommended dose is one-
tenth of the dose of neoarsphenamine. Since
4 to 4.5 gms. of neoarsphenamine was used
in the preceding series, a total dose of .4 gms.
or 400 mgs. of Mapharsen was administered
by intravenous drip similar to that used with
neoarsphenamine. It soon became obvious
that the toxicity of Mapharsen was so slight
that increased dosage could be safely em-
ployed. Because of failures with smaller doses,
the dosage was increased to 700 mgs. and then
by slow stages through levels of 800, 1000,
1100 and finally to the now recommended
standard dosage of 1200 mgs.®

Technique

Mapharsen is administered at the rate of
240 mgs. per day, daily for five days. It is
given at the rate of 20 mgs. per hour dis-
solved in 200 c.c. of 5 per cent glucose solution
continued for twelve hours. This represents
a total daily dose of 2400 c.c. of 5 per cent
glucose solution and 240 mgs. of Mapharsen.
This is truly heroic dosage since it represents
a daily dose of four times the amount usually
injected (60 mgs.) and a total of 20 standard
doses in five days. The injection is given by
slow drip at an approximate rate of 3 c.c. per
minute from a gravity burette. A vein on the

forearm below the cubital fossa is selected to
permit movement of the arm. Approximately
330 cases have now been treated with Ma-
pharsen by the New York group.

Reactions

The most frequent reactions encountered
are gastro-intestinal, and secondary fevers, oc-
curring usually on the day after treatment is
completed. Such febrile reactions are fre-
quently associated with a toxic skin eruption
of very temporary nature. No cases of ex-
foliative dermatitis have been encountered ;
likewise, no cases of blood dyscrasias, renal
or marked liver damage have been encoun-
tered. Neuritis, which occurred in 35 per cent
of the cases treated with neoarsphenamine
and was quite often severe, occurred in only
1.6 per cent of the Mapharsen series and was
very mild in character. The most feared reac-
tion is hemorrhagic encephalitis of which there I
were two cases in the neoarsphenamine series |
(111 cases), one resulting fatally, and three in
the Mapharsen series (330 cases) one being j
rather severe but resulting in recovery, and ’
two mild cases. Therefore, such treatment '
should not be recommended for general use
until more information as to the expected fre-
quency of such potentially serious reactions is
available.

Results

A longer period of observation will be nec-
essary to appraise adequately the results of
treatment with the Mapharsen group. Experi-
ence with relapse in early syphilis and with
the Mapharsen group observed for a longer
period of time would warrant the general
statement that if relapse is to occur it will
develop within one year. In the cases in the
Mapharsen series receiving a total dose of less
than 1000 mgs., there were twenty-ithree fail-
ures or 15 per cent of the 157 cases so treated.®
The patients receiving 1200 mgs. have not been
observed for sufficient time to attempt apprais-
al of final results, but latest reports suggest
that cure is expected in 91 per cent of these
cases. The course of treatment has been re-
peated in the majority of cases where failure
has occurred with success expected from this
second course and without any greater inci-
dence of reactions.

530

Jour. M.S.M.S.

FRACTURES OF NECK OE EEMUR— LA EERTE

This method of treatment is now being
tried out in many centers. The U. S. Public
Health Service is supervising its use in at
least one center in each of the states of the
North Central group, consisting of Michigan,
Ohio, Indiana, Illinois, Iowa, Wisconsin, Min-
nesota, and South Dakota. On the basis of
data collected from a large series of cases
treated in many centers, it is hoped that a
fairly accurate and rapid appraisal can be
made. An appraisal is particularly urgent
since such intensive treatment would be ideal
for use in our military forces.

Many possible variations, simplifications and
improvements of this method of treatment
suggest themselves. These may be worked
out in the future. The immediate problem is
confirmation through more extensive use of
the original New York method of treatment.

One hundred and seventy-five cases of pri-
mary and secondary syphilis have been treated
in Detroit with the assistance of Federal
fimds. A slight modification of the New York
Plan was used. The cases were diagnosed in
the Social Hygiene Clinic of the Detroit De-
partment of Health and hospitalized at Re-
ceiving and Herman Kiefer Hospitals. This
program of treatment was started in Novem-
ber, 1939. Males only were treated in the
New York series. The Detroit series is equal-
ly divided between males and females. There
have been no serious reactions. No sugges-
tive symptoms of hemorrhagic encephalitis
have been present to our knowledge. Results
of treatment are paralleling quite closely the
New York experience.

It is unfortunate that this method of treat-
ment has received so much premature public-
ity through newspapers and popular journals.
It has not been sufficiently emphasized in
such publicity that this method of treatment,
although promising, must still be considered
experimental ; that it is to be used only in
hospitalized cases under close observation for
evidence of intoxication; and, finally, that it
should be considered only, for the present
at least, in cases of early syphilis in the pri-
mary or secondary stage. There is very little
therapeutic experience with massive therapy
in latent or late syphilis. Syphilis in preg-

nancy may possibly prove a promising field,
but a potentially dangerous one. Results in
latent or late syphilis would be difficult to
appraise, and clinical experience with therapy
in this field would suggest that its use would
not have sufficient promise to justify its risks.

Bibliography

1. Baehr, George: Massive arsenotherapy in early syphilis by

the intravenous drip method. Arch. Derm, and Syph.,
42:240, (August) 1940.

2. Hirshfeld, S., Hyman, H. T., and Wanger, J. J. : Influence

of velocity on response to intravenous injections. Arch.
Int. Med., 47:259, (February) 1931.

3. Hyman, H. T., and Hirshfeld, S. : Therapeutics of intra-

venous drip. Jour. A.M.A., 100:305, (February 4) 1933.

4. Hyman, H. T., Chargin, L., and Leifer, W. : Massive dose

arsenotherapy of syphilis by intravenous drip method five-
year observations. Am. Jour. Med. Sci., 197:480, (April)
1939.

5. Hyman, H. T., Chargin, L., Rice, J. L., and Leifer, W. :
Massive dose chemotherapy of early syphilis by intravenous
drip method. Jour. A.M.A., 113:1208, (September 23)
1939.

6. Hyman, H. T. : Massive arsenotherapy in early syphilis,

clinical considerations. Arch. Derm, and Syph., 42:255,
(August) 1940.

Fractures of the Neck
of the Femur

A Technique for Rapid Nailing
Preliminary Report

By A. D. La Ferte, M.D.
Detroit, Michigan

A. D. La Ferte, M.D.

M.D., Jefferson Medical College, 1910.
Member of the staff of Harper and Provi-
dence Hospitals. Head of the Bone and
Joint Departments in Herman Kiefer and
Receiving Hospitals. Professor of Ortho-
pedic Surgery at the Wayne University Col-
lege of Medicine. _ Member of the Michigan
State Medical Society.

■ It has been long recognized that fractures
of the neck of the femur are difficult to treat,
and for that reason various methods of mechan-
ical fixation have been suggested. J. B. Murphy
reported excellent results in 1912 by using a
twelve penny nail in the fixation of ununited
fractures, while Smith-Petersen reported a series
of twenty-four cases in 1931 covering a period
of six years, in which he had used a three flanged
nail. In 1932 Wescott reported a modification
of the Smith-Petersen procedure, and Johansson
described a further modification by using a can-
nulated nail introduced over a Kirschner wire.
In 1934 King reported results with his method
somewhat similar to that of Johansson, while
Moore published the method and results obtained

July, 1941

531

FRACTURES OF NECK OF FEMUR— LA FERTE

by the use of three nails or pins in 1934 and
1936. Various other forms of mechanical fixa-
tion material have been introduced which have
not appealed to surgeons as have the use of

Fig. 1. Plumb line over coin.

Fig. 3. Tunnel and end pieces on ordinary operating table.

nails and pins. Plummer has done excellent
work on the method of localizing the nail and
Henderson has recently reported on a screw
which he has used in these cases.

It is my desire to discuss the subject from
a point of view which, I believe, has not been
mentioned: namely, the time element of in-
troduction as well as the anesthetic time
when using the various methods.

Age and Condition of Patients

Since fracture of the femoral neck occurs
more often in elderly people the time element in
reduction and fixation is important, as such
patients cannot be expected to tolerate prolonged
anesthesia and surgery without shock. It is in

order to minimize this danger that I desire to
present a method which reduces the time to a
minimum in reducing the fracture and introduc-
ing the nail.

Fig. 2. Thigh in internal rotation.

Elimination of Multiple X-ray Examinations |

It has been my experience in the reduction of !;
fractures of the neck of the femur that the •!
roentgenogram made following the reduction J
almost always showed a good apposition of the
fragments; in those in which the apposition was ■
not perfect, any subsequent manipulation failed i
to improve it. And further, the position in |
these few cases has always been satisfactory for
nailing.

With this observation it was decided toi ^
eliminate post-reduction x-ray examinations j I
made with the patient under anesthesia, and |
to proceed immediately with the operation. | j

Localization of Head

To localize the head of the bone prior to nail-
ing, a coin (10 cent piece) is placed just below
a point half way between the anterior superior ;
spine of the ilium and the spine of the pubis.
This is held in position by a small square of
adhesive tape. A roentgenogram is then made( j
prior to anesthesia with the tube centered with!
a plumb line over the coin (Fig. 1). After the (
film is developed the relationship of the coin-E
shadow to the head of the femur is noted, and, |
whether or not the shadow is superimposed over •
the center of the head, an exact relationship
is established to direct the nail.

Even though the coin is placed by a similar
measurement in each case, experience shows

Jour. M.S.M.S. j

532

FRACTURES OF NECK OF FEMUR— LA FERTE

Fig. 4. Case 4.

that its relationship to the head of the bone is
not constant. This, I believe, proves the futility
I of using a marker placed by measurement only,
and not localized by a roentgenogram as de-
scribed.

Antero-posterior Direction of Nail

The antero-posterior direction in which the nail
is to be driven is more difficult to estimate than
I the vertical since the angle of ante-version of
I the neck is not constant ; therefore I do not
i feel that any given number of degrees of inter-
j nal rotation will necessarily place the neck of the
I bone parallel with the operating table. Follow-
' ing the reduction of the fracture, an assistant
holds the knee flexed to 90 degrees and the thigh
is internally rotated to a tension just before ele-
vation of the pelvis would occur on the fracture
side. The internal rotation at this point will
place the neck of femur on a plane parallel with
the tunnel upon which the patient rests (Fig. 2).

Tunnel

The tunnel is constructed of rigid material so
that the weight of the patient will not cause
the upper surface to sag and interfere with the
introduction and removal of the x-ray film holder.

Equipment and Nail

The operation is done on an ordinary operat-
ing table, the tunnel resting on the center section
of the table, while at either end are wooden
platforms fitted to the table to prevent sliding,
and high enough to equal that of the tunnel;
these end platforms hold it in position. At oper-

ation the tunnel opening is placed opposite the
fracture side, thus allowing the x-ray technician
to place his portable unit so that he may intro-
duce and remove the films without interfering
with the operator (Fig. 3). The length of the
nail to be used is estimated by attaching to the
skin with adhesive tape a calibrated metal bar
four inches in length lateral to the trochanter on
the unaffected side. A roentgenogram of the
hip is made and since the metal bar is the same
distance from the film as the neck of the femur,
a comparison of the two allows one to secure a
nail of suitable length.

Operative Procedure

With the tunnel and platforms in position the patient
is placed on the operating table. If the coin localiza-
tion has not already been made it is done at this time.
The lower abdomen and entire thigh are sterilized.
The leg is wrapped in a sterile sheet or stockinet to
allow for free handling; anesthesia, preferably penta-
thol sodium, is then given. The fracture is reduced
by the Leadbetter method and the leg held by an
assistant, with the thigh parallel to the table, slightly
abducted and internally rotated as described. An in-
cision, ranging from three to five inches in length, de-
pending upon the depth of the soft tissues, is made
from the upper border of the trochanter, allowing just
enough exposure to locate the inferior border of the
trochanter and to palpate the anterior and posterior
limits of the shaft; it is important to palpate the
posterior limit of the shaft since there is usually some
expansion of the bone at this point and unless this is
noted, the nail will be started too far anteriorly.

With the localization film in view on a shadow box,
the coin shadow is noted, estimating the entrance and
direction in which the nail is to be driven. The nail
starter is seldom used, as oozing over the shaft of

July, 1941

533

FRACTURES OF NECK OF FEMUR— LA FERT£

Fig. 5. Case 6.

the bone may obscure the starter cuts ; constant spong-
ing delays progress. There has been no difficulty in
driving the nail directly into the shaft and when it has
been “driven home” the thigh is gently flexed to de-
termine that the nail has not entered the acetabulum
and that it is not impinging on the joint cartilage.
The fragments are then impacted with three or four
sharp blows on the Smith-Petersen impactor. The
driver handle is removed, the wound covered and the
anesthetic discontinued. An antero-posterior roent-
genogram is then made with the thigh on the table and
in internal rotation. Without moving the x-ray tube a
lateral film is made with the thigh in 90 degrees flex-
ion and slight abduction. While these films are being
developed the wound is closed and a dressing applied.
If the films disclose the nail to be in a satisfactory
position the patient is returned to bed. If, however.

Summary |

1. Nailing is the method of choice in the treat- |
ment of most cases of fracture of the neck of '
the femur, and in some cases of intertrochanteric
fractures,

2. Most of these fractures occur in old, debili-
tated people who should not be subjected to
lengthy operative procedures or prolonged an-
esthesia.

3. I have shown that repeated roentgen rays
are unnecessary during operation.

4. Postoperative ray examination and opera-
tion are accomplished on an ordinary operating
table.

the position should not be satisfactory, I would open
the wound and proceed again.

Reduction in Time

Since my first case, which took forty minutes
and in which there was a lack of definite tech-
nique, and my second, which took fifty minutes, I
have been able to reduce and nail these fractures
in from seven to eighteen minutes ; this time in-
cluded the reduction of the fracture, the inser-
tion of the nail, the taking of the films, and the
closure of the wound.

It is not possible at this time to give the final
results obtained in the several fractures nailed
by this technique. These will, however, be re-
ported when sufficient time has elapsed.

In this report the purpose has been to de-
scribe a technique by which fractures of the
neck of the femur can, with reasonable certainty,
be nailed in a few minutes, thus bringing all but
the extremely feeble into the field of good opera-
tive risks.

5. A rigid upper surface on the film tunnel
that will not sag is essential.

6. X-ray localization of the head by means of
a plum line over a coin gives a dependable, rela-
tive position.

7. The operation of nailing such a fracture
can be done efficiently in a few minutes, thus
avoiding shock in most instances.

Bibliography

Johansson, Sven; Zur Tecknik der Osteosynthese der

Fract. Femoris. (Vorlaufige Mitteliung). Zentralbl. f. Chir.,
59:2019, 1932. ^ ,

King, Thomas: Recent intracapsular fractures of the neck

of the femur: A critical consideration of their treatment

and a description of a new technique. Med. Jour. Austra-
lia, 1:5, 1934. ^ ^ ,

Leadbetter, G. W.: A treatment for fractures of the

neck of the femur. Jour. Bone and Joint Surg., 15:931-940,
(October) 1933. .... , .

Moore, Austin; Fractures of the hip joint (intracapsular).
A new method of skeletal fixation. Jour. South Carolina
Med. Assoc., 30:199-205, (October) 1934. , ,

Murphy, J. B.: Ununited fractures of the neck of the

femur. Murphy Clinics, 1:165-175, 1912.

O’Meara, J. W. : Fractures of the femoral neck treated by

blind nailing. Jour. Bone and Joint Surg., 17:928-932,
(October) 1935. j it /- j

Smith-Petersen, M. N., Cave, E. F., and VanCxorder,
G. W.; Intracapsular fractures of the neck of the femur.
Treatment by internal fixation. Arch. Surg., 23:715, 1931.
White J. Warren; An instrument facilitating use of the
flanged nail in treatment of fractures of the hip. Jour.
Bone and Joint Surgery, 17 :106S-1066, (October) 1935.

Jour. M.S.M.S.

534

POSTPARTUM STERILIZATION— BIRCH

Postpartum Sterilization

By William G. Birch, M.D.

Sault Ste. Marie, Michigan

William G. Birch, M.D.

M.B., Northwestern University Medical
School, 1932. M.D., Northwestern University

Medical School, 1933. Attending Obstetrician
and Gynecologist, War Memorial Hospital,

Sault Ste. Marie, Michigan. Member of the
Staff _ of Sault Polyclinic. Member of the
Michigan State Medical Society.

■ During the past ten years there has been

shown an increased interest in the problem of
imitation of family size. Accentuated economic
tension is in part responsible for this trend, but
enlightenment of the laity with maternal wel-
fare programs, supervised by governmental, med-
ical and private agencies, also plays its part.
Distribution of birth control information by the
physician, once a crime, is now widely recog-
nized and approved.

The techniques of spacing childbirths are mul-
titudinous and of vaiying degrees of effective-
ness. Where permanent cessation of childbear-
ing function is desirable, the practice of ligation
or resection of the Fallopian tubes has become
standard. As usually carried out, an important
obstacle in many instances was the delay in its
accomplishment. The patient was advised to
return in from three to six months following her
last pregnancy for her operation. All too often
she would return before that time, again in a
pregnant state. Extra hospital expenses have
also caused delay with pregnancy intervening.
To circumvent this possibility, it has been the
policy of some of the larger institutions to per-
form a cesarean section at term for the primary
purpose of sterilization — a truly major proceed-
ing.

In 1937, while I was Resident at the Chicago
Lying-In Hospital, there was begun the practice
of sterilizing the patient wdthin twenty-four
hours after her delivery’, providing no potential
infection could be detected. In 1939, Adair and
Brown reported the results with fifty cases.

In early 1940, Hewitt and Whitley reported 106
cases sterilized an hour after delivery’. Earlier
literature includes only the work of Skajaa in
Switzerland, who, in 1932, reported a series
sterilized within one month of confinement. His
series showed an alarmingly high incidence of

July, 1941

embolism and thrombo-phlebitis, ranging as high
as 40 per cent in some groups.

The recent reports are much more gratifying
and indicate a solution of the problem which is
both efficient and safe. The purpose of this
paper is to discuss indications and stress tech-
nique as well as to present 35 more cases.

Indications

At the present time one cannot make any
definite assertions regarding the indications for
permanent sterilization without risk of contro-
versy.

The medical profession as a whole does not
agree as to what conditions warrant definite
steps being taken to prevent occurrence of
further pregnancies in an individual. In gen-
eral it may be said that indications for the
prevention of pregnancy are more flexible than
they are for termination by therapeutic abor-
tion once the process has begun.

There are many who are advised against hav-
ing more babies who should not be interrupted
if they become pregnant. It is my feeling that
those who are suffering from definite, life-short-
ening, organic disease should be spared the
risk and anxiety of pregnancies which would un-
doubtedly further shorten their lives, or increase
the degree of invalidism to which they are re-
stricted. I feel it unwise to allow an individual
who is able to carry’ on activity only if she has
no more pregnancies, to become pregnant again.
It appears logical to expect more responsibility
of a mother toward her present family than to-
ward any possible additions in the future.

There is another large group of patients,
besides those who fall within the category
of organic disease, which presents a constant
problem to the medical profession. This group
might be called the Functional Group. The
patients of this group may have no definite
hazardous organic disease but they present a
combination of symptoms and findings which
make further childbearing highly inadvisable.

One might divide this group into those who
have poor protoplasm and those who have ex-
hausted protoplasm. Among those of the first
classification are individuals who are, and have

535

POSTPARTUM STERILIZATION— BIRCH

always been frail and ailing. Their resistance
is poor and they react poorly to pregnancy. The
physician is always relieved after their delivery
and eventual recovery. These patients are a
constant hazard in our morbidity and mortality
statistics. Of similar make-up but different
cause are those in which vitality is exhausted.
Originally healthy and robust, poor living condi-
tions and too frequent pregnancies have worn
them out before their time. They appear to be
years older than their actual ages. No phy-
sician in practice is unfamiliar with the pasty,
haggard features of the woman who has had
too many babies and has given too much of
her substance in their procreation.

I feel that these women are entitled to cease
childbearing, and with the consent of their hus-
bands, to tahe active steps to prevent the possi-
bility of its recurrence. It is for these two
groups of patients that early postpartum sterili-
zation is admirably adapted.

It should, however, be stressed that the
ultimate responsibility of the individual phy-
sician for deciding which patients should be
sterilized is great. He should always bear in
mind that this procedure is irrevocable, and
should weigh the facts carefully in order that
he might do nothing which could work great
harm and unhappiness in years to come. Steri-
lization should not be done, except under
urgent necessity without not only the con-
sent, but the wholehearted endorsement of
both the husband and wife.

It should be carefully explained that meno-
pause will not begin and that marital relation-
ships will not be altered, in order to completely
dispel any misinformation which the patient may
have entertained.

Prerequisite Conditions

Certain conditions must be observed if one is
to minimize the risk associated with this opera-
tion. Though convalescence is remarkably un-
eventful in most instances, the physician must
always remember that this is a major operation,
and as such is safe only if the greatest care- is
exercised in pre-operative preparation, which
should be started during pregnancy. It is strong-
ly felt that the good results obtained are due
to a great degree because local anaesthesia is

used. With this in mind, the patient should
be mentally prepared before going to the hospital.
She should be told that she will have a local
and that there will be some pain, but that the ;
postoperative freedom from gas pains and vomit- ’
ing more than offset the immediate discomfort.

She must be in the best possible condition. '
Anemia should be corrected during pregnancy, j
if present, and any vitamin deficiency eliminated. |

Operation should not be undertaken if there
is any acute infection such as coryza or pyelitis,
or if the patient has undergone a prolonged
•labor or complicated delivery, with its potential
danger of infection. . It is felt by some that
tubal resection may act to limit spread of in-
fection, under such circumstances, but evidence
is insufficient on this point, as yet.

Technique

Pre-operatively, the patient is given, the night before,
a moderately heavy dosage of a barbiturate. This in-
sures a good rest after the tiring experiences of labor
and leaves the patient slightly drowsy the following
morning. A half hour before the scheduled time for I
the operation, she is given, depending on her size, either
six or seven and a half grains of Seconal which is
followed in fifteen minutes by a hypodermic of one- j
quarter grain of morphine. 1

By the time she reaches the operating room she will,
in most instances be sound asleep and will not remem-
ber, afterwards, any of the details of her operation.
Quiet is observed so as not to disturb the patient.
The abdominal wall is infiltrated with 0.5 per cent novo-
cain to which adrenalin has been added. This infiltra-
tion is carried out between the umbilicus and symphy-
sis, special care being exercised to block off the seg-
mental nerves to that region. An incision approximately
3 inches in length is then made just below the um-
bilicus through the skin and subcutaneous fat exposing
the fascia. The fascia is then infiltrated, after which
it is incised and the rectus muscles are separated.
The peritoneum is not infiltrated, as this does not
appear to have any effect upon its sensitivity. It is
incised, care being taken not to cause undue tension,
as this is most uncomfortable and rough handling
may cause the patient to react. The forefinger of
the right hand is slipped behind the right tube at
the uterine cornu, and the uterus is slightly rotated
bringing the tube into the operative field. The tube
is then grasped with Allis’ forceps, care being taken
not to damage the utero-ovarian anastomosis which
courses in the folds of peritoneum just below the
tube proper. One half c.c. of novocain is injected into
the interstitial tissue between the tubal serosa and
the muscularis. This procedure is for two purposes ;
(1) to anaesthetize the tissues and (2) to cause sepa-
ration of the tube proper from the serosa covering it.

A longitudinal incision is made in the serosa for

Jour. M.S.M.S.

536

POSTPARTUM STERIITZATIOX— BIRCH

inches and the tube is separated by blunt dissec-
tion from the connective tissue in which it is imbed-
ded. Two black silk ties are placed about the tube an
inch apart and the intervening tube is removed. The
incision in the serosa is closed, burj'ing the proximal
end in the mesosalpinx and turning the distal end
out toward the peritoneal cavity. A similar procedure
is carried out on the left tube and the abdomen is
closed in layers.

It is to be stressed that during the entire op-
eration the greatest care possible is taken to be
gentle with the tissues handled, and to use strict
aseptic technique. There is no doubt but that
trauma to the pelvic organs is easier during preg-
nancy and the puerperium. The blood vessels
are markedly dilated and the tissues softened and
it is much more easy to bruise them than when
they are in the normal state. When the opera-
tion is smoothly executed the bowel and the
omentum are not disturbed — an important point
in the prevention of distention.

Postoperatively, the patient is given morphine
as required. The evening of the first day she is
given a soft diet and liquids as desired. A gen-
eral diet is given the third day. Enemas and
laxatives are ordered as needed. Sutures are

removed the seventh day and the patient is al-
lowed to sit up on the same day if the incision is
healed. She is sent home on the ninth post-
operative day if she is convalescing satisfactorily.
The dressing is removed after three weeks but
otherwise the later postpartum period is treated
in no different manner than in any other par-
turient.

Cases

These thirty-five cases differ from those pre-
viously reported in the literature in that they
are entirely those which occur in an average type
private practice, whereas the others were clinic
patients. Probably a slight majority of them
are in a low income bracket, while some would
classify as definitely underprivileged. All had
prenatal care, including complete physical exam-
inations, hemoglobin and red count determina-
tions, Kahn tests, and frequent urinalyses, be-
sides any specially indicated laboratoiy* work.

There have been no deaths in the series and
the morbidity, based on a reading of 38 degrees
(C) at two different times after the first twent}*-
four hours, was 2.8 per cent (one case). The
one case showing morbidity had lochiometra but

rapidly became afebrile and was discharged on
the ninth postoperative day.

The average age of all patients was twenty-
eight years and four months. The average parity
was four and one-half. These figures parallel
those of the Adair and Brown series. The
youngest patient was twenty-two and the old-
est thirty-seven. Eighteen were classified as
having organic disease as follows :

Toxemia 5

Rheumatic heart disease 2

Chronic nephritis 3

Tuberculosis 2

Cardiac asthma 1

Cholecystitis ■ 2

Psoriasis 1

Psychoneurosis 1

Diabetes 1

The functional group totaled seventeen cases,
most of whom were of the exhausted type. xAll
showed definite impairment of general good
health, although no serious organic disease could
be demonstrated.

The type of delivery was predominately spon-
taneous. Spontaneous deliveries totaled twenty-
three, of which 16 were repaired, two having old
third degree lacerations. Twelve were delivered
with forceps of which five had repair work
done. Probably more repairs would have been
reported, if it had not been that in the early
cases repair was not attempted. More recently
perineorrhaphy has been done whenever needed
without any apparent lengthening of convales-
cence.

The average time elapsed postpartum before
operation was 26 hours. The average post-
operative stay in the hospital was nine and
one-half days, with a maximum of fourteen
days in the case of one patient who had a mild
infection without fever, of a third degree repair.

Deliveries during the three years in which this
series of cases was compiled totaled 480 cases,
an incidence of sterilization amounting to 7.5
per cent. Nine cases were referred by other
physicans with a specific request for sterilization
based on either organic or functional indications.
Had it not been for these nine cases the inci-
dence would have been lower.

Discussion

It is felt that the optimum time for post-
partum sterilization is within the first tw^enty-
four hours, after the patient has had time to

July, 1941

537

POSTPARTUM STERILIZATION— BIRCH

recover from the immediate effects of her labor,
and after there is assurance that there will
be no postpartum hemorrhage. Hewitt and
Whitley performed their sterilizations an hour
after their patient’s delivery. It is felt that
this might be hazardous from the point of view
of possible hemorrhage. Skajaa’s reports show
increasing danger of phlebitism and embolism
as time increases up to five weeks.

The use of a local anaesthetic is important
inasmuch as it causes a minimum of altera-
tion from normal postpartum recovery. It
has been found that local anaesthesia without
sedation does not allow sufficient relaxation
and prevention of anxiety to prevent straining
and consequent exposure of other abdominal
viscera with resultant increase in postopera-
tive discomfort and distention. Sedation re-
sults in the patient sleeping most of the rest of
the day of operation when she would otherwise
be suffering her greatest pain. It is not un-
usual for her to have practically no discomfort
after the first day. The use of a small incision
is stressed, as this prevents protrusion of
the other abdominal viscera and results in
better and faster healing.

Conclusion

In conclusion I would like to say first that
although indications for sterilization are dis-
cussed, it is not my desire to attempt to establish
absolute indications for sterilization, as they can
be only relative. For this, as for any other
operative procedure, the individual physician is
a better judge of whether or not a patient should
be sterilized. There are those who believe in
sterilization only for very serious organic le-
sions. There are those who do not believe in
sterilization at all. It is not my desire to con-
vert those individuals to another point of view,
but rather to present, to those who have need
for such an operation in their practice, a tech-
nique which has been found both safe and
practicable.

Widespread and indiscriminate sterilization
can easily become a social menace but it is
my belief that judiciously performed, it may
well be a powerful prophylactic measure for
further aid in reducing maternal morbidity
and mortality.

It has been the experience of those who have I
done this type of operation that where care is I
used in the selection of cases, and performance |
of the operation is accomplished with gentle- ^
ness and skill, the patient undergoes no undue
risk. Adequate prenatal care is to be stressed.
Operation should not be done if labor has been •
prolonged or if delivery was complicated.

Tubal resection was performed in most in- i
stances in this series. Ligation after crushing
no doubt is satisfactory, but it is our feeling
that it is not as safe. It is a more simple pro-
cedure, with less opportunity for troublesome
bleeding from the tube, but the time saved in
doing it in preference to resection is insignificant
where local anaesthesia is used. It is again to
be stressed that this is a permanent procedure,
without recall, and that the responsibility of de-
cision should not be taken without considering
all factors carefully. Where all conditions im-
posed are adequately met, we have found this
operation will fulfill the requirements with a
minimum of hospitalization and a maximum of
efficiency and safety.

Summary

1. Thirty-five cases of early postpartum steri-
lization in private practice are reported.

2. Possible indications are discussed but it
is emphasized that each sterilization is an indi-
vidual problem to be solved by the physician in
charge of the case only after careful evaluation
of all factors.

3. Local infiltration after adequate sedation is
advised in place of inhalation anaesthesia, the
former being more safe and resulting in less
upset to the patient’s postpartum routine.

4. Postpartum sterilization offers the advan-
tages (1) of elimination of accidental pregnancy
after childbirth in those in whom are found
indications for sterilization and (2) of minimum
hospitalization and expense to the patient.

5. Morbidity is not appreciably increased and
no mortality has occurred in this series.

Bibliography

1. Adair and Brown: Amer. Jour. Obstet. and Gynec., 37:472,

1939.

2. Hewitt and Whitley: Amer. Jour. Obstet. and Gynec., 39:

649, 1940.

3. Skajaa: Acta obstet. et gynec., 12:114, 1932.

538

Jour. M.S.^I.S.

Afflicted-Crippled Children

The uniform Afflicted-Crippled Children Bill, draft-
ed by the Alichigan State Medical Society and seven
other organizations interested in the indigent sick
child, was not acceptable to Michigan’s House of Rep-
resentatives. Certain influences throughout the state
made impossible the passage of this model legislation.
Therefore, the medical profession must work (for two
more years, at least) under the present crippled child
and afflicted child laws which leave much to be desired.

Our doctors of medicine must continue, however, to
give primary consideration to the sick child and to
render proper care and treatment to these unfortunate
crippled and afflicted adolescents, despite the weak-
nesses of the present laws. The profession must aid in
the establishment of medical examination boards or
filters to help control the patient-intake; otherwise the
present appropriations, which should be adequate, will
be dissipated.

Last but just as important, each physician must
work diligently during the next eighteen months to in-
form his patients and the public concerning the vital
need for improved legislation covering Alichigan’s
crippled and afflicted children.

President, Michigan State Medical Society

f^reiident

/d

a^e

July, 1941

539

Editorial

DISCUSSION CONFERENCES

■ In two months the Seventy-sixth Annual

Meeting of the Michigan State Medical Society
will be held in Grand Rapids.

Ever since last winter the officers of the Scien-
tific Sections, The Council, and the Secretaries
have been working steadily and continuously
preparing a program even better than that of
the Diamond Anniversary Meeting last year.

The splendid facilities of Grand Rapids in
handling this meeting, in providing hotel accom-
modations, convenient meeting halls, and space
for exhibits, make conditions favorable for suc-
cess.

The adoption of open discussion periods in
which the presentations of the day will be in-
formally considered, with time for -questions and
requests for further clarification, is welcomed.
This unique innovation should, in itself, warrant
your intense consideration.

The Scientific Sections this year will have pro-
grams planned which will be more extensive and
even more practical than those of previous years,
and will present to the membership the best
possible internationally known speakers on medi-
cal subjects as well as the cream of the state’s
practitioners and teachers.

VACATIONS

■ The most unsuccessful case that the average

doctor treats is himself. When that patient
begins to show signs of the wear and tear of day
and night service to his profession; when the
imaginary pains of his patients become real tor-
ture to the physician, or the stuffing and glutting
of the obese matron down at the corner causes
the doctor to bolt his own food and forsake his
table companionship to prescribe ; then it is time
for him to take his own medicine,- which usually
is a vacation.

Without detracting from the value of medical

meetings it must be clear that to this physician ■
a convention is not a vacation. '

i

There are certain rules for a doctor’s vacation ^
which are, if not paramount, indeed advisable:
first, avoid telephones as you would a Grand \
Jury; second, never register as -‘Doctor”; third, \
don’t take your medical cases along with you >
(if you distrust your colleagues, hide in one of '
your traveling bags a very small first-aid outfit) ; ^
fourth, do not visit hospitals, medical schools, '
other doctors (unless they are close personal *
friends) ; fifth, don’t put yourself on a time I
schedule; sixth, even if you don’t obey any of j
these commandments, at least take a vacation.

THE PLATFORM OF THE AMERICAN ,

MEDICAL ASSOCIATION j

The American Medical Association advocates:

1. The establishment of an agency of federal ;

government under which shall be coordinated and \ •
administered all medical and health functions of the 1
federal government exclusive of those of the Army i
and Navy. :

2. The allotment of such funds as the Congress i
may make available to any state in actual need for
the prevention of disease, the promotion of health
and the care of the sick on proof of such need.

3. The principle that the care of the public health ,
and the provision of medical service to the sick is
primarily a local responsibility.

4. The development of a mechanism for meet-

ing the needs of expansion of preventive medical
services with local determination of needs and local
control of administration. i

5. The extension of medical care for the indigent
and the medically indigent with local determination
of needs and local control of administration.

i

6. In the extension of medical services to all the

people, the utmost utilization of qualified medical |
and hospital facilities already established. ,

i

7. The continued development of the private
practice of medicine, subject to such changes as may ,
be necessary to maintain the quality of medical serv-
ices and to increase their availability.

8. Expansion of public health and medical serv-
ices consistent with the American system of democ-
racy.

540

Jour. M.S.M.S.

EDITORIAL

REFUGE FROM RAGWEED

■ Last summer the State Health Laboratory of
Michigan, aided by contribution from the
Michigan Hotel Association, made a pollen count
of areas throughout the entire state.

The map which is reproduced here by permis-
sion of the Michigan Department of Health is
self-explanatory and should serve both as a guide
to the physician and as an advertisement for the
state as a refuge for those unfortunates who are
allergic to the pollen of ragweed.

MAY THE OSTEOPATH DO SURGERY?

Because of the similarity between the laws per-
mitting the practice of osteopathy in Michigan
and in Nebraska the following opinion of the
Nebraska Supreme Court should be of interest
to all physicians who ask the question, “May an
osteopath practice med.icine and surgery?”

Through the kindness of Mr. M. C. Smith,
Executive Secretary of the Nebraska State Medi-
cal Association, it is possible to present this inter-
esting and possibly suggestive decision.

This is a suit brought by the attorney general to
enjoin the defendant, Roy Jackson Gable, an osteo-
pathic physician, from engaging in the practice of
medicine and operative surgery within this state and
from publicly professing to be a physician, surgeon,
or obstetrician. The defendant filed an answer in
which he denied that he had ever engaged in the prac-
tice of medicine, or professed publicly any right to do
so. He alleges, however, that he is an osteopathic phy-

JULY, 1941

sician, surgeon and obstetrician and asserts a right to
engage in the practice of operative surgery and ob-
stetrics and to hold himself out to the public as one
qualified to do so. The attorney general thereupon
moved for a judgment on the pleadings, which was
overruled by the trial court, and a judgment entered
in favor of the defendant. The state thereupon ap-
pealed.

The question whether the defendant may lawfully
engage in the practice and dispensing of medicine is
not an issue on this appeal. Whether defendant may
lawfully engage in the practice of operative surgery
and obstetrics and engage in the use of anesthetics in
the manner alleged in defendant’s answer are the ques-
tions presented by the motion for judgment on the
pleadings. The correctness of the trial court’s ruling
on this motion is the controlling factor in this appeal.

The defendant alleges that he is a graduate of the
American School of Osteopathy at Kirksville, Mis-
souri, a school of osteopathy recognized by the Ameri-
can Osteopathic Association. On June 13, 1922, defendant
was issued a license to practice as an osteopathic phy-
sician and surgeon by the department of public welfare
of the state of Nebraska. The answer admits and

541

MISCELLANEOUS

alleges that defendant has performed surgical opera-
tions, including tonsillectomies, appendectomies, circum-
cisions, an amputation of a toe, rectal operations, hyster-
ectomies, operations for hooded clitoris and lapa-
rotomies, all of such operations being performed Avith
instruments and by incisions of the patients’ bodies ;
that he has engaged in the practice of obstetrics and has
used anesthetics ; all of which the defendant alleges
that he will continue to do under claim of right.

It cannot be questioned that a person engaging in
the practice of medicine and surgery without the re-
quired statutory license may be restrained by injunc-
tion. * * * If^ therefore, the admissions and allegations
of defendant’s answer constitute the practice of medi-
cine and surgery as defined by section 71-1401, Comp.
St. 1929, the defendant should be enjoined from so
doing. If said acts are within the scope of the practice
of osteopathy as defined by our statutes on the subject,
the defendant is then within his rights and not subject
to restraint for so doing.

The question is raised whether the character and
general duties of occupations classed as professions are
determined as questions of law or fact. We think the
rule is that they are questions of fact of which the
courts will take judicial notice. Certainly, the question
whether a specific act constitutes the practice of osteo-
pathy is not subject to proof by expert witnesses. The
absurdities which would be certain to follow such a
construction of the rule in question are too obvious to
require an exposition here. The general rule of plead-
ing which admits are true all facts well pleaded upon
the filing of a general demurrer or a motion for a
judgment on the pleadings, has no application to facts
of which a court may take judicial notice, and such
demurrer or motion does not, therefore, admit a con-
clusion of law deduced from such facts.

The general rule seems to be : “There is apparently
no dissent from the proposition that in the considera-
tion of a pleading the courts must read the same as if
it contained a statement of all matters of which they
are required to take judicial notice, even when the
pleading contains an express allegation to the con-
trary.” * *

Applying this rule to the pleadings before us, the
allegations of defendant’s answer to the effect that
the acts admitted constitute the practice of osteopathy
are mere conclusions of law. The allegation of a sound
conclusion of law is always treated as superfluous and
the allegation of an unsound conclusion is entirely dis-
regarded. It matters not in the instant case whether
the conclusions pleaded are true or not, for that which
is judicially known may not be successfully contro-
verted by pleadings, or made issuable by them. * * *

This court is, therefore, required to determine the
meaning of the term “osteopathy” in the same manner
as any other fact of which it is required to take judicial
notice. It may resort to the definition and description
of it given by the founder of the practice, by those who
teach and practice it, and by the lexicographers who
define it as a science. ^ *

Much has been written by the founder of osteopathy,
and others learned in the practice of its profession,
as to the fundamentals of the science of osteopathy.
To give a resume of these writings would imduly
lengthen this opinion. We think a fair conclusion to
be drawn from all of them was ably expressed in
Bragg V. State, 134 Ala. 165, 32 So. 767, where the
supreme court of Alabama said : “The method of
treatment by the practitioners of osteopathy is a sys-
tem of manipulation of the limbs and body of the
patient with the hands, by kneading, rubbing or press-
ing upon the parts of the body. In the treatment, no
drug, medicine or other substance is administered or
applied, either internally or externally; nor is the knife
used or any form of surgery resorted to in the treat-
ment. The practitioner himself performs the manip-
ulations. The teaching and theory of those skilled in
osteopathy are, that it is a system of treatment of dis-

ease by adjustment of all the parts of the body me-
chanically. It is taught that any minute or gross de-
rangement of bony parts ; contracting and hardening
of muscles or other tissue; or other mechanical de-
rangements of the anatomical parts of the body which
must be in perfect order mechanically, in order that
it may perform its function aright, nerve centers,
arteries, veins and lymphatics, which must function
properly in order that health may be maintained. It is
taught that such interferences lend to congestion, ob-
structed circulation of blood and lymph, irritation of
nerves and abnormal state or nerve centers ; that the
result is disease which can be cured only by righting
what is mechanically wrong. * * * The essential things
taught in the schools of osteopathy are anatomy, physi-
ology, hygiene, histology, pathology and the treatment
of diseases by manipulation. The repudiation of drugs
and medicine in the treatment of diseases is a basic
principle of osteopathy and a knowledge of drugs
or medicines, their administration for the cure of dis-
eases, the writing and giving of prescriptions, are not
essential to the graduation of, and the issuance of
diplomas to, students of osteopathy.”

The well-settled definitions of osteopathy, in the
writings of Dr. Andrew Taylor Still, its founder, and
in the writings of recognized practitioners, as well as
in the dictionaries and the decisions of the courts, all
uniformly hold that the system of osteopathy adminis-
ters no drugs and uses no knife. * * * With these
definitions and observations in mind, the licensing stat-
utes must be examined to determine the extent to which
this definition has been modified in this state by legis-
lative action. Section 71-1701, Comp. St. 1929, pro-
vides: “For the purpose of this article the following
classes of persons shall be deemed to be engaged in
the practice of osteopathy: 1. Persons publicly pro-

fessing to be osteopaths or publicly professing to assume
the duties incident to the practice of osteopathy. 2. Per-
sons who treat human ailments by that system of the
healing art which places the chief emphasis on the
structural integrity of the body mechanism as being
the most important factor for maining (maintaining)
the organism in health.” Section 71-1702, Comp. St.
1929, sets out certain exceptions which are not relevant
in this suit.

Provisions are then made for the examination and
licensing of those who would practice osteopathy.
Among the requirements is the presentation of proof
that the applicant was graduated from an accredited
school or college of osteopathy. * * * The following
section defines an accredited school of osteopathy.
Among the conditions required is that the course of
study must include the following subjects: Anatomy;
chemistry ; pathology ; toxicology ; pediatrics ; general
surgery ; obstetrics ; histology ; physiology ; hygiene ;
dietetics ; practice, therapeutics, general diagnosis and
technique ; dermatology and syphilis ; orthopedic sur-
gery ; gynecology ; embryology ; bacteriology ; compara-
tive therapeutics; nervous and mental diseases; juris-
prudence, ethics and economics ; genito-urinary dis-
eases ; and eye, ear, nose and throat. * * * The section
following this provides : “Every license issued under
this division shall confer upon the holder thereof the
right to practice osteopathy in all its branches, as
taught in the osteopathic colleges recognized by the
American Osteopathic Association.” * * *

The argument is made that as general surgery, ortho-
pedic surgery, anatomy, pathology and other subjects
are included in the required course of study in an
accredited school of osteopathy, their practice is in-
cluded in the statutory authorization by virtue of the
use of the words, “The right to practice osteopathy in
all its branches, as taught in the osteopathic colleges
recognized by the American Osteopathic Association.”
The words of this statute do not authorize a licensed
osteopath to practice everything that he is taught in an
osteopathic school. It contains expressions which have
a limiting as well as an authorizing effect. The prac-

542

Tour. M.S.AI.S.

MISCELLANEOUS

tice authorized must be osteopathic and it must also
be as taught in accredited osteopathic colleges. The
fact that branches of medicine and surgery may be
taught to increase the knowledge of the student in
the anatomy and functions of the various parts of
the human body for the purpose of better fitting him to
practice osteopathy will not warrant him to invade
those fields on the theory that they constitute the prac-
tice of osteopathy. The scope of osteopathy is well
known and schools and colleges of osteopathy must
stay within its boundaries, they cannot enlarge them.

* * * In a case similar in principle, the supreme court

of California said : “While the section contains the

additional clause ‘as taught in chiropractic schools or
colleges,’ the entire section must be taken as a whole
and it cannot be taken as authorizing a license to do
anything and everything that might b^e taught in such
a school. A short course in surgery or one in law
might be given, incidentally, and it would not follow
that the section would then authorize a licensed chiro-
practor to engage in such other professions. It is not
sufficient that a particular practice is taught in such
a school. Under the terms of the statute it must meet
the further test that it is a part of chiropractic, what-
ever that philosophy or method may be, and further
that it shall not violate the provision which expressly
forbids the practice of medicine. If such a practice is
not a part of chiropractic but does constitute the prac-
tice of medicine, it is not authorized under this license
even though it may be taught in such a school.” * * *

This point is well summed up in Georgia Ass’n of
Osteopathic Physicians and Surgeons v. Allen, 31 Fed.
Supp. 206, wherein the court said: “His knowledge
must be broader than his practice ; he must know what
he practices but may not practice all he knows.”

The argument is advanced that the use of the words
“osteopathic physician and surgeon” in the license im-
plies the right to practice surgery. The word “surgery”
used in its general sense in connection with the pro-
fession of osteopathy means surgery by manual manip-
ulation and was never meant to include operative sur-
gery as we now understand it. The correctness of this
statement is evidenced by the very principles of osteop-
athy to the effect that the general use of a knife or
other instruments in surgical operations was regarded
as unnecessary and opposed to the osteopathic system
of treatment. The practice of osteopathy and operative
surgery has long been recognized as two separate and
distinct things. Separate boards have been set up in
this state for the examination of those applying for
licenses to practice medicine and surgery and those
desiring to practice osteopathy. It is urged that the
principles of osteopathy have changed and that ex-
perience and learning have produced certain advances
that must be recognized. If osteopathy has changed
merely by a self-serving attempt to broaden its scope
by invading fields requiring a different license, we can
only say that the legislature has never recognized any
such additions to the profession. If the changes are
the result of advancements in the profession, of course,
they still constitute the practice of osteopathy. But
the practice of operative surgery by an osteopath is an
invasion of the field of the physician and surgeon as it
is generally known and is not an evolutionary advance-
ment of the profession of osteopathy. * * *

Respondent argues that, as the act of 1919 * * *
contained the provision that “Osteopathic physicians
shall perform only such operations in surgery as was
fully taught in the school or college of which the
applicant is a graduate at the time of his attendance,”
it thereby recognizes operative surgery as a branch of
osteopathy. This contention is too broad. Much of
the difficulty in this class of cases has arisen because
of the varied use of the term “surgery.” It originated
from the latin “chirurgia,” meaning “hand work” or,
as another writer puts it, “To work with the hand.”

* * * This is the meaning attributed to it in all the
earlier writings on the subject of osteopathy and ac-

JULY, 1941

coimts for the general usage of the word in designat-
ing an osteopath as an osteopathic physician and sur-
geon. The invasion of the field of medicine and opera-
tive surgery as it is generally understood seems to be
based on an attempt to broaden the definition of the
term “surgery” as formerly used so as to include opera-
tive surgery. The field cannot be so extended. The
words in the 1919 act must, therefore, be construed as
referring to operations in surgery consistent with the
practice of osteopathy as originally defined, which ex-
cludes the practice of operative surgery in its com-
monly accepted meaning.

We conclude, therefore, that an osteopathic physician
and surgeon is not authorized under the statutes of
Nebraska to engage in the practice of operative sur-
gery and that the trial court was in error in holding
to the contrary.

Realtor contends that the respondent cannot engage
in the practice of obstetrics without a license to prac-
tice medicine and surgery as defined by section 71-1401,
Comp. St. 1929. That a practicing physician and sur-
geon, properly licensed under the statute, may engage
in the practice of obstetrics is not disputed. Tlie right
to practice obstetrics is not specifically granted by the
statute authorizing the licensing of osteopathic physi-
cians and surgeons. It is not disputed that respondent
graduated from an accredited school of osteopathy, the
requirements of which include the study of obstetrics.
In the respects noted, respondent is in no better posi-
tion than he was as to his right to practice operative
surgery. But we are again required to examine the
statutes to determine to what extent, if any, they
have modified this position. Under the provisions of
the 1901 act, an osteopath was required to report to
the proper authorities all cases of contagious diseases,
deaths or birth. * * * This same provision appears in
the act of 1905. * * * In, 1909 a new statute was enacted
which provided that osteopathic physicians shall report
all births the same as physicians of schools of medicine.

* * * This provision was retained in the act of 1919.

* * * In 1927 this section was amended to read as fol-
lows : “A birth certificate in the form prescribed by
the department of public welfare, and conforming to
all of the requirements of the United States census
bureau shall be filled out by the physician in attendance,
and signed in his own handwriting. If there is no
physician in attendance, then said certificate shall be
completed and signed by the parent or other person
present. Such certificate shall be filed with the local
registrar within five days after any birth.” * * *

It will be noted that the present law does not spe-
cifically require an osteopath to file birth certificates
with the department of public welfare, the require-
ment being that the birth certificate shall be filled out
by the physician in attendance.

To obtain a license to practice osteopathy, respondent
was required to exhibit a diploma issued by a regular
school of osteopathy wherein the curriculum included
instruction in certain subjects required by statute, one of
which was obstetrics. He was also required to pass an
examination in the required subjects. While these facts
alone would not authorize respondent to engage in the
practice of obstetrics, yet, when considered with the
statute regarding the reporting of childbirths, together
with the history of its development, we think the legis-
lature authorized respondent, upon securing a license
to practice osteopathy, to engage in the practice of
obstetrics. As was said in Stoike v. Weseman, 167 IMinn.
266, 208 N. W. 993 : “Unless an osteopathic physician
could lawfully attend a woman in childbirth, there
would be no reason for requiring him to report the
birth of the child.” Of course, the present statute does
not specifically require an osteopath to report births,
but the former statute did, and we do not think the
enactment of the present law evidences any intent to
limit the practice of the osteopath in the field of ob-
stetrics from that which had theretofore existed. It is
(Continued on Page 565)

543

OUTLINE OF GENERAL ASSEMBLY PROGRAM
Seventy-sixth Annual Meeting, Michigan State Medical Society
Grand Rapids — September 17, 18, 19, 1941

f

1

4

Wednesday, September 17

Thursday, September 18

Friday, September 19

A. M.
9:30 to
10:00

Medicine

Russell L. Cecil, M.D.
New York City

Obstetrics (Maternal Health)
James R. McCord, M.D.
Atlanta, Georgia

ON THE

SEVEN SECTION PROGRAMS

General Medicine
A. R. Barnes, M.D.
Rochester, Minn

Surgery

Harry E. Mock, M.D.
Chicago

10:00 to
10:30

Surgery

Elliott C. Cutler, M.D.
Boston

Medicine (Tuberculosis)
Charles E. Lyght, M.D.
Northfield, Minn.

10:30 to
11:00

VIEW EXHIBITS

VIEW EXHIBITS

Obstetrics & Gynecology
Richard TeLinde, M.D.
Baltimore

11:00 to
11:30

Syphilology

Francis E. Senear, M.D.
Chicago

Medicine

V. P. Sydenstricker, M.D.
Augusta, Georgia

Ophthalmology & Otolaryngology
Samuel Iglaueh, M.D.
Cincinnati

Pediatrics

Harold K. Faber, M.D.

San Francisco

Dermatology & Syphilology
S. Wm. Becker, M.D.
Chicago

11:30 to
12:00

Gynecology

George W. Kosmak, M.D.
New York City

Pediatrics

James Gamble, M.D.
Boston

P. M.
12:00 to
12:30

Medicine (Mental Hygiene)
Lawrence Kolb, M.D.
Washington, D. C.

Obstetrics

Wm. E. Caldwell, M.D.
New York City

Radiology, Pathology, Anesthesia
Bernard H. Nichols, M.D.
Cleveland

12:30 to
1:30

LUNCHEON
VIEW EXHIBITS

LUNCHEON
VIEW EXHIBITS

LUNCHEON
VIEW EXHIBITS

1:30 to
2:00

Anesthesia

Wesley Bourne, M.D.
Montreal

Ophthalmology
Alfred Cowan, M.D.
Philadelphia

Otolaryngology

D. E. Staunton Wishart, M.D.
Toronto

2:00 to
2:30

Surgery (Indus. Health)
A. J. Lanza, M.D.
New York City

Pathology

Shields Warren, M.D.
Boston

Dermatology

Carroll S. Wright, M.D.
Philadelphia

2:30 to
3:00

VIEW EXHIBITS

VIEW EXHIBITS

VIEW EXHIBITS

3:00 to
3:30

Pediatrics

Henry Poncher, M.D.
Chicago

Medicine

Chester S. Keefer, M.D.
Boston

Pediatrics (Child Welfare)
E. C. Mitchell, M.D.
Memphis

3:30 to
4:30

DISCUSSION
CONFERENCES
WITH GUEST
ESSAYISTS

' DISCUSSION

CONFERENCES
WITH GUEST
ESSAYISTS

3:00 to 4:00
Medicine
C. A. Doan, M.D
Columbus

4:00 to 4:30
Surgery

Owen H. Wangensteen, M.D.
Minneapolis

8:30 to
10:00

President’s Night
Biddle Oration
in Hotel Ballroom
Speaker:

Alphonse Schwitalla, S.J.

Smoker

in Pantlind Hotel Ballroom

END OF
CONVENTION

Dancing

544

Jour. M.S.M.S.

THE 7Bth AIVIVUAL MEETIIVG

GRAND RAPIDS -1941

OFFICIAL CALL

The Michigan State Medical Society
will convene in Annual Session in Grand
Rapids, Michigan, on September 16, 17,
18, 19, 1941. The provisions of the
Constitution and By-laws and the
Official Program will govern the delib-
erations.

P. R. Urmston, M.D., President

A. S. Brunk, M.D., Chairman of The
Council

O. D. Stryker, M.D., Speaker

Attest : L. Fernald Foster, M.D.,

Secretary

Aerial View of Grand Rapids,
Host City to the 1941 Con-
vention of the Michigan State
Medical Society to be held
September 16, 17, 18, 19.

HOUSE OF DELEGATES, 1941

Ball Room, Pantlind Hotel, Grand Rapids
Order of Business*

SESSIONS OF THE HOUSE
OF DELEGATES

TUESDAY, SEPTEMBER 16, 1941
8 :00 a.m. Sharp — Delegates’ Breakfast, Swiss
Room

9 :00 a.m. Sharp — First Session, Ball Room

TUESDAY, SEPTEMBER 16, 1941
Pantlind Hotel, Grand Rapids

8 :00 a.m. Delegates’ Breakfast, Swiss Room
9 :00 a.m. First Session, Ball Room
3 :00 p.m. Second Session, Ball Room
5:15 p.m. Special Pre-view of Exhibits

1. Call to order by the Speaker

2. Report of Committee on Credentials

3. Roll Call

4. Appointment of Reference Committees:

On Officers’ Reports
On Reports of The Council
On Reports of Standing Committees
On Reports of Special Committees
On Amendments to Constitution and By-
laws

On Resolutions

8 :00 p.m. Third Session, Ball Room

*See the Constitution, Article IV, and the By-laws, Chapter
3, on the “House of Delegates.”

July, 1941

545

THE 76TH ANNUAL MEETING

5. Speaker’s Address — O. D. Stryker, M.D.,
Fremont

6. President’s Address — P. R. Urmston, M.D.,
Bay City

7. President-Elect’s Address — Henry R. Car-
stens, M.D., Detroit

8. Annual Report of The Council — A. S. Brunk,
M.D., Detroit, Chairman

9. Report of Delegates to American Medical
Association — Henry A. Luce, M.D., Detroit,
Chairman

10. Resolutions**

11. Reports of Standing Committees:

(a) Legislative Committee

(b) Committee on Distribution of Medical
Care

(c) Medical-Legal Committee

(d) Representatives to Joint Committee on
Health Education

(e) Preventive Medicine Committee

Cancer

Maternal Health
Syphilis Control
Tuberculosis Control
Industrial Health
Mental Hygiene
Child Welfare
Iodized Salt

Heart and Degenerative Diseases

12. Reports of Special Committees:

(a) Committee on Nurses’ Training Schools

(b) Conference Committee on Pre-Licensure
Medical Education

(c) Radio Committee

(d) Advisory Committee to Woman’s Aux-
iliary

(e) Scientific Work Committee

(f) Medical Preparedness Committee

Recess

TUESDAY, SEPTEMBER 16, 1941

3 :00 p.m. Sharp — Second Session — Ball Room

1. Supplementary Report of Committee on
Credentials

•*A11 resolutions, special reports, and new business shall
be presented in duplicate. (By-laws, Chapter 3, Section 7-n.)

2. Roll Call I

3. Unfinished Business 1

4. New Business** ,

5. Reports of Reference Committees:

(a) On Officers’ Reports

(b) On Reports of The Council

(c) On Reports of Standing Committees '

(d) On Reports of Special Committees

(e) On Amendments to Constitution and
By-laws

(f) On Resolutions

5:15 to 6:30 p.m.— RECESS FOR SPECIAL PRE-
VIEW OF EXHIBITS

TUESDAY, SEPTEMBER 16, 1941
8 :00 p.m. Sharp — Third Session, Ball Room

1. Supplementary Report of Committee on
Credentials

2. Roll Call

3. Supplementary Report from The Council

4. Supplementary Reports from Reference
Committees

5. Elections:

(a) Councilors:

1st District — C. E. Umphrey, M.D., De-
troit— incumbent

4th District — R. J. Hubbell, M.D., Kala-
mazoo— incumbent

5th District — Vernor M. Moore, M.D.,
Grand Rapids — incumbent i

6th District — Ray S. Morrish, M.D.,j
Flint — incumbent 1

(b) Delegate to American Medical Associa-j

tion: I

L. G. Christian, M.D., Lansing — in-j
cumbent

Alternate Delegates to American Med-J
ical Association: |

George J. Curry, M.D., Flint — in-|
cumbent |

Ralph H. Pino, M.D., Detroit — in- 1
cumbent

(c) President-elect

(d) Speaker of House of Delegates |

(e) Vice Speaker of House of Delegates

Adjournment ;

Civic Auditorium, Grand Rapids

All activities of the 76th M.S.M.S. Convention — 110 Technical and Scien-
tific Exhibits and all Scientific Sessions — will be held in this spacious,
modern auditorium, September 16, 17, 18, 19, 1941.

546

Tour. M.S.M.S.

>f YOU AND YOUR BUSINESS ><-

ANNUAL REPORT OF
LEGISLATIVE COMMITTEE, 1940-41

In connection with the meeting of Michigan’s Legis-
lature, your Legislative Committee held five meetings
during the past year : on October 24 and November 13,
1940; February 13, March 20 and April 24, 1941.

Fifty-one Bills Affected Medical Practice

The 61st Michigan Legislature convened on January
1 and adjourned on May 27, 1941, leaving behind a
good record so far as legislation affecting the medical
profession is concerned. The Legislature was ex-
tremely slow in getting under way but more than com-
pensated for its tardy start by the super-accerelation
of the final weeks. During the session 1,058 bills were
introduced of which 51 dealt directly with the practice
of medicine. A number of important resolutions was
also considered. These 51 medical bills and the resolu-
tions were carefully studied and necessary contacts
made either for or against, as circumstances demanded.
Of these 51 bills, 13 passed the Legislature; an addi-
tional five passed one house but died in the other
branch ; and the balance were either killed on the
floor or died in committee.

No bill objectionable to the mediccd profession was
passed at this session, although a score of inimical
measures was introduced!

I

Thanks

The hundreds of alert physicians back home — our
key-men — who constantly kept their friends in the
Senate and House informed concerning medical legis-
lation are mainly responsible for this good record. The
legislators looked to their local medical friends for
advice; they appreciated the opportunity to be of serv-
ice. So again, the Legislative Committee expresses its
thanks to every doctor who contacted his legislator
during the past five active months. Without this won-
derful help and cooperation the legislative program of
the Michigan State Medical Society would not have
been successful.

The Committee also is sincerely grateful to the far-
sighted Council of the Michigan State Medical Society
for its constant encouragement of the Legislative Com-
mittee in its nerve-wracking job.

The Legislative Committee again expresses apprecia-
tion and gratitude to the intelligent and health-minded
members of the Michigan Legislature for the courteous
reception they extended the representatives of the
medical profession and the thoughtful consideration
they gave to medical and health measures coming be-
fore them.

To h’s Excellency, Governor Murray D. Van Wagon-
er, the Legislative Committee reiterates its thanks for
the friendly cooperation his office extended to the medi-
cal profession in all health matters.

Below are listed the 51 bills which vitally affected
the medical profession. A brief description of the
proposals together with the action taken is presented.

Bills Passed by the Legislature

HB-215 — To permit free choice of physician by wel-
fare clients, by removing exemption of citv physician
and city pharmacist’s offices in Detroit. Passed with
amendment to permit the welfare client to choose
either his private physician or the city physician’s
office. S'gned by the Governor (P.A. 343).

HB-84 — Deficiency appropriation for dieted and
crippled children totaling $435,452.13, of which $115,-

JULY, 1941

632.51 was payable to doctors of medicine, was passed
and signed by the Governor (P.A. 14).

HB-483 — Deficiency appropriation of $200,000 ($60,-
000 for afflicted and $140,000 for crippled) for afflicted
and crippled children services to June 30, 1941, was
passed and signed by the Governor (P.A. 110).

HB-402 — Appropriating $1,802,295 for medical and
hospital services of afflicted and crippled children for
the fiscal year ending June 30, 1942, and $1,821,450 for
the following year, was passed and signed by the
Governor (HEA 215).

HB-129 — To regulate the sale of prophylactic devices
for the prevention of venereal diseases. Passed and
signed by the Governor (P.A. 276).

HB-565 — To provide for half payment by the state
of costs of hospitalization of afflicted adults. Passed
and presented to the Governor for approval (HEA
196).

HB-341 — To give county and district boards of health
the same powers now given by law to township and
county boards of health, was passed and signed by
the Governor (P.A. 198).

SB-400 — To permit a board of governors for Wayne
University, Detroit. Passed and presented to the Gov-
ernor for approval (P.A. 248).

SB-71 — Requiring payment of fees to persons ordered
to take a physical examination by any court, board,
etc., passed and signed by the Governor (P.A. 18).

SB-81 — To establish a crime detection laboratory in
the State Health Department, for the use of the Michi-
gan State Police, was passed and signed by the Gov-
ernor (P.A. 62).

SB-218 — To amend the mental defectives sterilization
act to make the law applicable to additional state in-
stitutions, passed and signed by the Governor (P.A.
109).

SB-248 — To license operators of water treatment
plants. This bill sponsored by the water treatment
plants operator’s association, was approved by the
MSMS. Passed and presented to the Governor for
approval (P.A. 239).

SB-134 — To regulate sale and possession of valerium,
passed and signed by the Governor (P.A. 140).

Bills Approved by One House

SB-250 — To provide for Afflicted-Crippled Children
Commission. This bill (same as HB-317) was de-
veloped after a year’s work by committees of the State
Medical Society working in cooperation with repre-
sentatives of the American Legion, Veterans of Foreign
Wars, the Michigan Welfare League, the Michigan
Hospital Association, the Forty and Eight, the Chil-
dren’s Fund of Michigan, and the Michigan Society for
Crippled Children, and seemed to meet the requirements
to end the confusion of the three-headed administration
now existing. The bill passed the Senate by a good
majority without damaging amendment, but failed to
be reported out of the House Social Aid and Welfare
Committee.

The afflicted-crippled children bill was added as an
amendment to HB-402, passed the Senate, but was re-
fused by the House as “not germane” to this appropria-
tion bill.

The bill was finally attached to HB-565 as an amend-
ment, passed the Senate, but the House refused to
concur in the Senate Amendment. The model afflicted-
crippled child proposal died in conference committee
5 :30 a.m. the last morning of the session.

HB-131 — To regulate the sale of barbituric acid and

547

YOU AND YOUR BUSINESS

its derivatives, sulfanilamide and its derivatives, and
other so-called “Knock-out” drugs. After a stormy
battle, this bill finally passed the house with objection-
able osteopathic and “bookkeeping” amendments ; the
Senate removed the House amendments but made other
changes in the bill which were not agreeable to the
House. The bill died in conference committee.

SB-66 — To raise medical compensation for occupa-
tional diseases and eliminate specific enumeration of
“occupational diseases.” Passed by Senate with many
amendments, but died in House Labor Committee.

HB-217 — To require “settlement” of pauper before
rendition of surgery or treatment of afflicted adults at
public expense. Passed House, but died in Senate.

HB-517 — To authorize detention of adult voluntary
applicants as full pay patients by state mental institu-
tions ; and to permit 35 to 60-day observation and treat-
ment periods for suspected mental cases. Passed
House, but died in Senate Public Health Committee.

Bills Which Died in House of Origin

SB-95 — To permit osteopaths to participate in group
medical care plans. Killed in Senate Insurance Com-
mittee.

HB-110 — To establish enabling act for group osteo-
pathic care. Died in House Insurance Committee.

HB-209 — To repeal the Basic Science Law. Died in
House Public Health Committee.

HB-119 — To set maximum fee of $3 for medical
examination of persons obtaining marriage license.
Died in House Public Health Committee.

SB-201 — To authorize examination and copying of
medical records, x-ray plates, charts, etc., of sick or
injured persons by attorney of patient. Killed in
Senate Judiciary Committee.

HB-190 — To establish a “board of examiners in
naturopathy.” Died in the House Public Health Com-
mittee.

HB-333 — To amend 1939 Welfare Law to prohibit
county medical societies from making contracts with
county welfare boards for medical relief ; to establish
uniform medical rates ; to open all hospitals to osteo-
paths. Died in House Social Aid and Welfare Com-
mittee.

HB-117 — To include as an occupational disease any
disease contracted by any employe or person engaged
in public health work. Died in House Labor Commit-
tee.

HB-72 — To add baker’s asthma to list of occupational
diseases. Died in House Labor Committee. ♦

HB-165 — To amend many sections of the workmen's
compensation law, including that portion concerning
occupational diseases. Died in House Labor Commit-
tee.

SB-205 and SB-206 — To amend the occupational dis-
ease law. Died in Senate Labor Committee.

HB-522 and HB-523 — To amend the occupational
disease law. Died in House Labor Committee.

HB-552 — ’To amend the occupational disease law.
Died in House Labor Committee.

SB-121 — To prohibit employment of minors under
16 years without certificate of physical fitness to be
given by public health officer or school physician. Died
in Senate Labor Cornmittee.

SB-122 — To prohibit employment of girls under 18
and boys under 14 in street trades without certificate
of physical fitness to be given by public health officer
or school physician. Died in Senate Labor Con^ittee.

SB-89^ — To place administration of afflicted child care
with state and county social welfare departments. Died
in Senate Welfare and Relief Committee.

HB-317 — (Same as SB-250, see comment elsewhere)
To establish an afflicted-crippled children cornmission.
Died in House Social Aid and Welfare Committee.

HB-297 — To provide for administration of afflicted-
crippled children program. Sponsored by probate judges
Died in House Social Aid-Welfare Committee.

SB-336 — To provide an entirely new welfare law 1
and combining the administration of the social welfare '
department and the afflicted and crippled children pro-
gram. Died in Senate Welfare and Relief Committee. ;

SB-79 — To penalize superintendent or executive in
charge of hospital for failing to render first-aid to
accident victims. Died in Senate Judiciary Committee.

SB-88 — To abolish office of coroner (except in Wayne
County) and establish state and county medical ex-
aminers. Died in Senate State Affsdrs Committee.

SB-101 — To define qualifications of coroners in coun-
ties having 100,000 and not more than 250,000 popula-
tion. Died in Senate State Affairs Committee.

SB-10 — To void claims made upon county which are
not acted upon by the county supervisors or county
board of auditors within 90 days after receipt of same.
Died in Senate Municipalities Committee.

HB-233 — To amend welfare law of 1939 to provide
half payment by the state for hospitalization of afflicted
adults. Killed in House and reintroduced as HB-565,
which passed.

SB-426 — To increase number of persons on State
Council of Health, plus other amendments to act
governing state health department. Died in Senate
Public Health Committee.

HB-580 — To establish a cancer bureau in the state
health department. Died in House Public Health Com-
mittee, which split on inclusion of damaging amend-
ments urged by osteopathic lobby.

SB-335 — To provide state aid to county health units,
to be limited to $3,000 each. Killed by the Senate.

SB-366 — To establish ragweed and mosquito ex-
termination study commission. Killed by the Senate.

SB-382 — To provide for uniform food, drug and
cosmetic act to conform with federal act. Died in
Senate Public Health Committee.

SB-272 — To revise pharmacy practice act. Died in
Senate Public Health Committee.

SB-275 — ^To amend the narcotic drug act. Died in
Senate Public Health Committee.

HB-342 — To create a State Council of Health which
would appoint the State Health Commissioner. Died
in House Public Health Committee. This proposal was
approved by the Michigan State Medical Society which
desired that the State Department of Health be di-
vorced from politics. However, legislators felt the
time was not ripe for passage of such a bill. Similar
legislation may be more favorably considered at a
future session.

Three Important Resolutions

House Resolution No. 48 — To demand an investiga-
tion of contracts between county medical societies and
county social welfare departments for medical care of
those on welfare, introduced by the osteopathic repre-
sentative in an effort to discredit the medical profession
and its care of those on medical relief, was killed on
the floor of the House.

House Concurrent Resolution No. 42 — To request de-
ferment of medical, dental, engineering and other pro-
fessional students from the draft, was adopted by the
Legislature.

Senate Concurrent Resolution No. 45 — To request aid
in providing financial and other aid for the training of
nurses, was adopted by the Legislature.

Recommendations

1. Your Legislative Committee respectfully stresses
the need for frequent and close contact with each leg-
islator (and other state and county office holders) by their
medical constituents, and reciprocity with our legislator-
friends in their capacities as professional and business
men. Contacts with public office holders are the definite
responsibility of the indiindual doctor. The most valu-

JouR. M.S.M.S.

548

YOU AND YOUR BUSINESS

able contact is made by the physician who knows or
renders professional service to the official.

We recommend that county medical societies give
tangible expression of appreciation to the Senators and
Representatives who proved themselves to be friends
of Medicine. These legislators should be shown, by
resolution or some other expression of thanks, that the
medical profession is grateful for their friendly co-
operation.

2. Concerning afflicted-crippled child legislation :
Your Legislative Committee worked unceasingly to
the final hour of the session for the passage of a
uniform afflicted-crippled child bill. However, certain
influences throughout the state made impossible the
passage of this model legislation. Therefore, the med-
ical profession must work (for two more years, at
least) under the present crippled child and afflicted
child laws which leave much to be desired. Your Leg-
islative ^Committee recommends, however, that phys-
icians continue to give primary consideration to the
sick child and to render proper care and treatment
to these unfortunate crippled and afflicted adolescents,
despite the weaknesses of the present laws. Further,
that the profession aid in the establishment and main-
tenance of medical examination boards or filters to
help control the patient-intake. Finally, that each doc-
tor work diligently during the next eighteen months
to inform his patients and the public concerning the
vital need for improved legislation covering Michigan’s
crippled and afflicted children.

3. Your committee reiterates its recommendation
that the State Board of Registration in Medicine be
urged to seek necessary changes in the Medical Prac-
tice Act, especially with reference to qualifications of
Board members, at the next session of the Legislature
as one of the Board’s major activities.

4. We recommend that Michigan physicians under-
stand the provisions and the dangerous import of the
Wagner Bill, the Brown-Wagner-Gleorge Hospital Con-
struction Bill, and other such legislation introduced into
the United States Congress. The Committee feels that
the American Medical Association should be con-
gratulated on the inauguration of its legislative bulle-
tin which keeps state societies well informed on Fed-
eral legislation to the end that the medical profession
is able to maintain eternal vigilance.

5. We recommend an active and financial interest
by the individual physician in other organizations and
committees which are seeking the same results as are
desired by the doctor of medicine. Support should be
given by the practitioner of medicine not only to his
county, state and national medical organizations, but
to fully accredited committees or leagues created to
uphold our constitutional form of government.

♦ ♦ ♦

Your Legislative Committee has spared neither time
nor effort in the State Society’s legislative work. We
believe we have gained further respect for the Michi-
gan State Medical Society from legislators, elected offi-
cers of the state, the press, and the general public. The
position of the State Society has been maintained and
strengthened.

Again, to all the hundreds who have responded to
our many requests for assistance, we thank you heart-
ily.

Respectfully submitted,

Harold A. Miller, M.D., Chairman

A. S. Brunk, M.D.

Henry R. Carstens, M.D.

H. H. Cummings, M.D.

L. A. Drolett, M.D.

T. K. Gruber, M.D.

S. L. Loupee, M.D.

G. L. McClellan, M.D.

H. L. Morris, M.D.

E. W. ScHNooR, M.D.

DEFERMENT OF MEDICAL STUDENTS

A resolution (H.C.R. No. 42), relative to the defer-
ment of certain draftees by selective service Boards, was
adopted by the Michigan Legislature May 16, 1941 :
“Whereas, It has come to the attention of the Legis-
lature that many young men who have not yet com-
pleted their college work are being compelled to give
up their studies and join the army; and

“Whereds, Many of these young men are not being
given any deferment by their Selective Service Boards;
and

“Whereas, A number of these students are taking
special medical, mechanical and engineering courses
that would tend to make them more valuable to the va-
rious medical and engineering units of the army ; there-
fore be it

“Resolved, by the House of Representatives (the
Senate concurring). That Louis B. Hershey, Acting
National Director and Colonel E. M. Rosecrans, State
Director of Selective Service, be and are hereby re-
quested to give additional consideration to occupational
deferments and to allow students in these specialized
courses to finish their work; and be it further
“Resolved, That a copy of this resolution be for-
warded to Louis B. Hershey, Col. E. M. Rosecrans,
(jovernor Murray D. Van Wagoner, and United States
Senators Arthur Vandenberg and Prentiss Brown.’’

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July, 1941

549

^ MICHIGAN’S DEPARTMENT OF HEALTH

HENRY A. MOYER, M.D., Commissioner, Lansing, Michigan

WILL THERE BE ANY POLIOMYELITIS
IN MICHIGAN THIS YEAR?

By S. D. Kramer, M.D.

The epidemic occurrence of poliomyelitis has proved
too uncertain as regards severity and location to make
any prediction possible. However, it has been repeatedly
observed that although it is common for sporadic cases
to recur in consecutive years in communities visited
by an outbreak, it is uncommon for an outbreak of
epidemic proportions to recur in the same community.
On the other hand, it is not uncommon for adjacent
communities, which had been spared in the previous
year, to be visited by an outbreak of epidemic propor-
tions during the following year or two. Applying such
notion to Michigan it might safely be assumed that
those communities of the upper peninsula which last
year experienced what must be regarded as severe out-
breaks, may have cases of the disease but will not
be attacked in epidemic proportions. Whether the dis-
ease will appear in adjacent communities in epidemic
proportions cannot, in the light of past experience, be
answered with any degree of exactness.

The extraordinary drain upon the patience and forti-
tude of physicians and health authorities which is so
regularly associated with this disease must be still
fresh in the minds of the medical fraternity of the
upper peninsula, and doubtless this concern will serve
to keep them on the alert for any recurrence of cases
this year.

It might perhaps be in point to attempt to bring up
to date the results of recent studies in so far as such
results may apply practically to the management of
future outbreaks of the disease. Practicing physicians
and organized health authorities naturally are interested
in new development relating to (1) control of the dis-
ease; (2) preventive measures; and (3) methods of
treatment, both general and specific.

Control of the Disease

The problem of control remains a difficult one. The
mode of the spread of the virus of poliomyelitis is
still too obscure and too difficult to trace for one to
offer any but very general rules of conduct during an
outbreak. Nevertheless, recent studies have yielded
some information of practical value. Vaughan and hils
collaborators of the Detroit Department of Health have
reaffirmed “contact” as one possible method of spread.
My own recovery of the virus from fecal material of
healthy contacts and the recovery of the virus by Paul
and Trask from the sewage system of areas in close
proximity to outbreaks, suggest other possible modes of
spread. Furthermore, my recovery of the virus from
infected fecal material that had been kept at ice-box
temperature for over six months indicates an extraor-
dinary^ resistance of the virus to certain physical fac-
tors

Although it is readily conceded that a consideration
of the above findings may not constitute complete nor
even adequate control, it would seem indicated that
these findings, which suggest the need for isolation,
quarantine, avoidance of contact with cases, and the
proper disposal of oral and fecal material from pa-
tients, should be applied by individual practitioners to
local home problems and included in the general health
procedures by health authorities.

Prophylaxis

There is no specific prophylactic measure available
for the prevention of this disease. The term prophy-

laxis might better be applied to the prevention and
amelioration of the crippling after-effects of the dis-
ease. In this connection emphasis must be placed on
early diagnosis, early splinting, and prolonged rest of
the affected parts.

It is not the purpose of this brief discussion of the
disease to enumerate the symptoms and laboratory
findings upon which a diagnosis of poliomyelitis may
be made, except to point out that in addition to the
clinical and laboratory findings, a consideration of cer-
tain epidemic features of the disease might prove a
useful guide in arriving at an early diagnosis. A
knowledge of the seasonal occurence of the disease
may prevent a “missed” diagnosis. Although the sea-
son at which the disease occurs may vary geographi-
cally, it is usually quite constant for any individual
locality. In Michigan poliomyelitis usually makes its
first appearance in June. A sharp increase in the num-
ber and concentration of cases during July generally
presages an outbreak. The peak of reported cases
usually is reached in August or early September, from
which point on there is a wane in the curve with sharp
reduction or disappearance of cases in October and
November. The age distribution of the disease should
be kept in mind. Although poliomyelitis may, and.
does, attack all age groups, it remains predominantly a
disease of childhood.

Special mention might be made perhaps of the im-
portance of certain physical findings in the diagnosing
of special forms of the disease. The rapidly fatal
bulbar forms of the disease and intercostal paralysis
must be diagnosed early if proper and adequate treat-
ments are to be effectively employed. Marked toxemia,
some difficulty in deglutition or aphonia, generally indi-
cate a bulbar form of the disease, whereas, a shallow
respiration associated with bilateral deltoid paralysis
may indicate early intercostal involvement. Such patients
are acutely ill and account for a large proportion of
the fatalities; consequently early diagnosis is of partic-
ular and lifesaving importance.

Treatment

There is no specific form of therapy for this disease.
As already stated it is not the purpose of this dis-
cussion to give the details of treatment for the patient
with poliomyelitis, except to point out certain important
measures that are necessary when dealing with bulbar
and intercostal forms of the disease.

As mentioned earlier, patients suffering from bulbar
forms of poliomyelitis must all be considered acutely
ill and prognosis in these cases should always be
guarded. Such patients should be promptly hospital-
ized. One of the most common complications in bulbar
poliomyelitis is involvment of the muscles of degluti-
tion. When this involvement is extensive these patients
literally choke to death because of their inability to
care for their own mucus and salfva. This difficulty
clearly points to the first steps to be taken in the treat-
ment, namely, to withhold all food by mouth, liquid
or solid, and to make every effort to keep the posterior
pharynx free of accumulated mucus. This is most
easily accomplished by postural drainage, the patient
being placed in a prone position with the head hanging
over the side of the bed. The application of gentle
suction accomplishes the same purpose, but care must
be employed not to traumatize the mucous membrane
by careless or injudicious use of the suction tube. Con-
stant bedside care by an intelligefit nurse is imperative.
Fluids and some degree of nutrition may be maintained

(Continued on Page 552)

5-SO

Jour. M.S.M.S.

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The strength of solutions required for various types of injections has
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for spinal anesthesia a total dose of from 50 mg. to 200 mg. (or the
equivalent 10 per cent solution, further diluted with spinal fluid).

Novocain is available, with and without Suprarenin*, in various sized
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July, 1941

Say you saw it in the Journal of the Michigan State Medical Society

551

MICHIGAN’S DEPARTMENT OF HEALTH

Main Entrance

SAWYER SAMTDHIUM
White Daks Farm

Marian, Ohio

For the treatment of
Nervous and Mental Diseases
and Associated Conditions

Licensed for

The Treatment of Mental Diseases
by the Department of Public Welfare
Division of Mental Diseases
of the State of Ohio

Accredited by

The American College of Surgeons
Member of

The American Hospital Association
and

The Ohio Hospital Association

Housebook giving details, pictures,
and rates will be sent upon request.
Telephone 2140. Address,

SAWYER SAMTDRIUM

White Oaks Farm

Marian, Ohia

(Continued front Page 556)
by the administration of 5 per cent glucose in saline
by intravenous drip or hypodermoclysis. Fluids or
food by mouth must be withheld until the patient has
demonstrated his ability to swallow.

The respiratory difficulty associated with bulbar forms
of the disease must be carefully distinguished from the
respiratory difficulties due to intercostal paralysis. Pa-
tients with bulbar poliomyelitis do not do well in the
respirator and it may even prove dangerous by com-
pelling a patient whose throat is full of mucus, to
aspirate such infected material into his trachae and
bronchi.

One of the most common causes for disappointment
in the use of the respirator is the failure to diagnose
intercostal paralysis sufficiently early. When paralysis
of these^ muscles is extensive and breathing is main-
tained by the diaphragm and the accessory muscles,
respiration cannot long be maintained and death fol-
lows. The intercostal muscles, of course, may be in-
volved only partially and adequate ventilation may be
maintained by the intact muscles for varying periods
of time, but the course of the disease is too unpredict-
able to assume that paralysis will not be progressive.
When the diagnosis of intercostal paralysis is made,
and this should be done early, the patient should be
removed to a hospital where a respirator will be avail-
able if needed.

Intercostal paralysis may be suspected by the t3Tpe of
respiration assumed by the patient in the early stages
of the involvement. The patient may be said to spare
his breath by talking very little or not at all, remain-
ing quietly awake for long intervals of time. Inter-
costal involvement is to be suspected particularly when
such “quiet wakefulness” is associated with unilateral
or bilateral deltoid paralysis. MTien properly used and
in time, the respirator is unquestionably a lifesaving
mechanism, but its use must not be delayed until the
patient has progressed to the point of exhaustion.

Treatment of paralysis of the voluntary skeletal
muscles may be summarized by the dictum of “early
splinting and prolonged rest.” The importance of this
dictum cannot be over-emphasized and there is a com-
plete agreement in this among orthopedic surgeons. It
has been my unfortunate experience to observe ex-
tremities permanently crippled by injudicious massage
and manipulation by well meaning individuals who were
ignorant of the underlying physiology. The problem
of splinting has been largely solved by the National
Foundation for Infantile Paralysis, Inc., which main-
tains a splint service without cost to the patient. The
splints may be obtained upon request by any respon-
sible person in the medical profession or by the local
county chapter officer of the Foundation.

ROCKY MOUNTAIN SPOTTED FEVER

The Maryland State Department of Health recently
reported five cases of Rocky Mountain spotted fever
or tick fever from widely separated parts of Maryland
during the month of May. There were two deaths from
the disease.

Tick fever occurs sporadically west of the Rocky
Mountain states and while there have been no proven
cases in Michigan, it may occur in this state. All phy-
sicians should bear this disease in mind when making a
differential diagnosis of a rash in a severely ill indi-
vidual which in its early stages simulates most closely
influenza, meningitis, measles, typhoid and typhus fevers.
This disease, caused by a Rickettsial organism, is one
of a number of related diseases of which typhus fever
is the most common. The Dermacentor ticks are re-
sponsible for Rocky Mountain spotted fever and in
the central and east portions of the United States the
vector chiefly responsible for its spread is the American
dog tick which fastens itself to horses, dogs and cattle

Jour. M.S.M.S.

552

MICHIGAN’S DEPARTMENT OF HEALTH

primarily and accidentally to human beings. The dis-
ease is contracted through the bite of the infected
insects or by crushing the tick on the skin and absorb-
ing the virus through a scratch, open cut or break
in the skin. It does not spread from person to person.

The incubation period varies between two and ten
days and the onset resembles influenza, followed by an
eruption which is first macular and then petechial and
covers the face, trunk, extremities and very commonly
the mucosa of the mouth and. pharynx. The rash may
be discrete but tends to coalesce and ranges from a
bright red to a brownish copper cast and may go on
to gangrene of the skin due to thrombi of the peripheral
vessels. The Weil-Felix reaction, while not .always
positive, is a valuable aid in the diagnosis of this
disease. A series of three blood samples should be
taken in each case, the first as soon as the disease is
suspected, the second approximately on the 12th day
I of the disease and the third during early convalescence.
[ Increasing titre of agglutinins constitutes a positive
i test.

! In sporadic cases, such as may occur in Michigan,

: it may be very difficult to differentiate typhus fever
from tick fever. However, in the former disease the
rash does not occur on the palms of the hands and
soles of the feet nor on the face or head and fades
with pressure, the Weil-Felix test will usually differen-
tiate the disease, there is usually no sloughing of de-
pendent parts of the body such as the scrotum or but-
tocks and fever declines by crisis or rapid lysis.

When removing a tick from a patient, care should
be taken not to crush the insect and if it is deeply
embedded, small forceps may dislodge it or a drop
of oil may be of help in withdrawing ticks followed by
an application of iodine to the wound.

Prophylaxis is by means of personal care in tick-
infested areas and the use of vaccine. Inasmuch as
the incidence of this disease is low in this area, it
is not wise to do wholesale vaccination of the popula-
tion but to depend upon personal hygiene with frequent
inspection of the body for ticks especially when the
individual is employed in a tick-infested area, or when
picnicking or camping.

100,000 KAHNS A MONTH!

Kahn tests now being done in Michigan public and
private laboratories are crowding the 100,000 mark in
monthly totals. April tests totaled 98,949, an all-time
high record. Previous highs were 89,002 in March, 1941,
and 85,782 in October, 1940.

The April total of 98,949 Kahn tests was divided as
follows: state laboratories 42,968 (a record), city
health department laboratories aided by state 21,560
(a record), private registered laboratories 34,421
(second highest total).

Selective Service examinations are contributing heavily
to the blood tests for syphilis being done in the De-
partment laboratories. Tests done for draft board phy-
sicians often ran 1,000 a day in April. Kahn tests for
Selective Service in the first four months were: Jan-
uary 12,405, February 11,407, March 17,933, April
19,749, May 20,585.

FBOM rOBTBAIX OF WILLIAM WITHEBING, M.O.

WnHERUVe HEIGHTS

DIGIFOLINE, offers the

physician a digitalis that may be
said to reach the heights of With-
ering’s therapy.

DIGIFOLINE "Ctha“

While disputes have raged as to the best
method of standardization, Digifohne
has not changed in rigidity of potency
testing for many years. The physician
can always be sure of this: — one tablet,
one cc. of liquid, or one (2 cc.) ampule
of Digifoline* is equivalent to one cat
unit. To sum up: this digitalis prepara-
tion is uniform and Ciba is constantly on
guard to maintain this high standard. No
glycerine or alcohol is present in the
ampules, thus eliminating any irritation
produced by these substances.

Oral, intravenous, intramuscular or
rectal administration in auricular fibril-
lation, congestive heart failirre, loss of
cardiac tone, etc.

NOT ENOUGH PUBLIC HEALTH NURSES

In Michigan, there are 976 public health nurses or
one nurse to 5,385 persons in the state’s population, ac-
cording to a recent survey of the Department. The
accepted ratio for effective and adequate public health
work is one nurse for 2,000 persons. Half the public
health nurses of Michigan are in Detroit. The ratio
there is one nurse to 3,326 persons; outstate it is one
nurse to 7,443 persons.

July, 1941

•Trade Mark Reg. U. S. Pat. Off. Word
“Digifoline” identifies the product as
digitalis glucosides of Ciba’s manufacture.

CIBA PHARMACEUTICAl PRODUCTS, Inc.

SUiniHIT NEW JERSEY

Say you saw it in the J ournal of the Michigan State Medical Society

553

t

>f Woman ^s Auxiliary ~K

Bay County

The Woman’s Auxiliary to the Bay County Medical
Society wound up its alTairs for this spring by giving a
complimentary tea for guests from Saginaw, Midland,
and other nearby communities at the Bay City Country
Club on Tuesday, May 13, from 3 to 5 o’clock in the
afternoon.

Between fifty and sixty guests attended the tea, the
majority from Bay City. We were very happy to have
Mrs. Roger V. Walker, state president, and Mrs. A. O.
Brown, state secretary-treasurer, both of Detroit,
with us.

Our president, Mrs. W. R. Ballard, and the two state
officers formed the receiving line for the party. Mrs.
Paul R. Urmston, Mrs. L. Fernald Foster, Mrs. Colin
A. Stewart, and Mrs. H. M. Gale were invited to pre-
side at the tea table during the afternoon.

Mrs. George M. Brown was general chairman of the
party, assisted by Mrs. R. E. Scrafford, Mrs. Kenneth
Stuart, Mrs. A. D. Allen, and Mrs. D. J. Mosier. —
Mrs. Paul L. DeWaele.

Genesee County

The May meeting of Genesee Medical Society Auxil-
iary was held in the Federation Clubhouse. A board
meeting preceded the regular luncheon meeting.

Stephen Gelenger, M.D., spoke on “Medical Defense
Preparation.” Henry Cook, M.D., Chairman of the In-
dustrial Health Committee, AfSMS, talked on “The
Physician as an Industrialist.”

A report on the ticket sale for the play, “Ladies of
the Jury,” to be presented by the Flint Community

Players under sponsorship of the Auxiliary, was given.
Proceeds from the play, which was very successful,
were given to British War Relief.

The charity work engaged in throughout the year
was discussed and plans were made to care for a doc-
tor’s widow during the summer. We have provided
for this woman and her family for more than a year.

Our delegates to the convention of Woman’s Auxil-
iary to the American Medical Association were Mrs.
William Hubbard, Mrs. J. H. Curtin, Mrs. Gordon
Willoughby, and Mrs. O. J. Preston. — (Mrs. N. A.)
Margaret A. Gleason.

Kalamazoo County

The annual meeting of the Woman’s Auxiliary, Kala-
mazoo Academy of Medicine, was at the home of Mrs.
W. G. Hoebeke on May 21. Mrs. James Malone was
the assisting hostess.

A cooperative dinner was enjoyed by the twenty-one
members present. The business meeting followed, and
annual reports of all committee chairmen were given.
The new officers elected for the coming year were :
president, Mrs. Sherman Gregg; president-elect, Mrs.
James Malone; vice president, Mrs. Roscoe Hildreth;
secretary, Mrs. John Fopeano; treasurer, Mrs. Hugo
Aach.

Plans for a picnic to be held June 11 at the summer
home of Mrs. F. E. Grant, Gull Lake, were discussed.

The program for the meeting was furnished by ^frs.
Florence Fiske, of the Kalamazoo Tuberculosis Asso-
ciation, who showed several very interesting films on
the prevention and cure of tuberculosis. — Mrs. Ger.\ld
H. (Frances) Rigterink.

(DUE TO NEISSERIA GONORRHEAE)

Ci?!

ilver Picrate,
Wyeth, has a convincing record of
effectiveness as a local treatment for
acute anterior urethritis caused by
Neisseria gonorrheae.^ An aqueous
solution (0.5 percent) of silver pic-
rate or water-soluble jelly (0.5 per-
cent) are employed in the treatment.

Acomplete technique of treatment and liferaturewill besentupon request

*Silver Picrate is a definite crystalline compound of silver and picric acid.
It is available in the form of crystals and soluble trituration for the prepara-
tion of solutions, suppositories, water-soluble jelly, and powder for vaginal
insufflation.

1. Knight, F., and Shelanski,
H. A., "Treatment of Acute Ante-
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Am. J. Syph., Gon. & Ven. Dis.,
23, 201 (March), 1939.

JOHN WYETH & BROTHER, INCORPORATED, PHILADELPHIA

Jour. M.S.M.S.

554

Say you saw it in the Journal of the Michigan State Medical Society

-K COUNTY AND PERSONAL ACTIVITIES -k

100 Per Cent Club for 1941

Allegan

Manistee

Barry

Menominee

Clinton

Muskegon

Dickinson-Iron

Oceana

Eaton

Ontonagon

Grand Traverse-

Ottawa

Leelanau-Benzie

Saginaw

Huron

Saint Clair

Ingham

Saint Joseph

Jackson

Sanilac

Lapeer

Shiawassee

Lenawee

Tuscola

Luce

W'exford-Missaukee

The above County Medical Societies have cer-

tified 1941 membership

for all of their 1940

members. Several more

societies are not on

the 100 per cent roll because of only one de-

linquent member.

Wm. A. Lange, M.D., Detroit, addressed the meeting
of the Dickinson-Iron County Medical Society at Iron
Mountain on June 5 to which all doctors and dentists
in the western half of the Upper Peninsula were in-
vited. Doctor Lange gave a paper on “Reconstructive
Surgery About the Face and Neck” which was illus-
trated with colored slides and motion pictures. Twenty-
five guests in addition to fifteen members were present
for the joint meeting.

Red, White and Blue! The June issue of the Bulle-
tin of the Calhoun County Medical Society appeared
with red and blue type on white paper giving an at-
tractive patriotic note to this informative bulletin.

♦ ♦ :(5

Correction! The name of Carl Hanna, M.D., for-
merly of Detroit, and now serving as Lt. Colonel in
the 107th Medical Regiment at Camp Livingston, Lou-
isiana, was inadvertently omitted from the Roster of
members published in the May Journal. Apologies !

^ ^

A record attendance of 243 medical golfers played
in the 26th Annual Tournament of the American Med-
ical Golfing Association on June 2, 1941, over the
Cleveland Country Club and Pepper Pike courses. The
championship was won by George R. Love, M.D., of
Oconomowoc, Wisconsin, with a low gross of 149 for
the 36 holes. John M. Murphy, M.D., of Detroit, 1940
AMGA Champion, placed third with a gross of 152.
G. T. McKean, M.D., of Detroit, won a prize in the
championship flight.

Harry E. Mock, M.D., Chicago, was elected pres-
ident; John B. Morgan, M.D., Cleveland, first vice
president, and H. V. Hubbard, M.D., Plainfield, N. J.,
second vice president, of the AMGA for the coming
year. Bill Burns was reappointed executive secretary.
The next AMGA Tournament will be held in Atlantic
City in June, 1942.

WEHENKEL SAIVATORICM

A MODERN, comfortable sanatorium adequately equipped for all types of medical and
surgical treatment of tuberculosis. Sanatorium easily reached by way of Michigan
Highway Number 53 to Corner of Gates St., Romeo, Michigan.

For Detailed Information Regarding Rates and Admission Apply

DR. A. M. WEHENKELy Medical Director, City Offices, Madison 3312*3

July, 1941

555

COUNTY AND PERSONAL ACTIVITIES

See why

BABY FOODS

are extra easy

to digest

(Statement accepted by the AMA Council on Foods) y

The twentieth annual scientific and clinical session of
the American Congress of Physical Therapy will be
held September 1 to 5 inclusive, 1941, at the Mayflower,
Washington, D, C. The mornings will be devoted to
the annual instruction course and the afternoons and
evenings will be devoted to the scientific and clinical
sessions. The seminar and convention proper will be
open to all physicians and qualified technicians. For
information concerning the seminar and preliminary
program of the convention proper, address the Amer-
ican Congress of Physical Therapy, 30 North Michigan
Avenue, Chicago.

♦ ♦ ♦

Premarital Examinations: Doctor, in questionable
cases arising under this particular law, you have the
privilege of contacting the State Health Commissioner
as regards special certification for marriage.

The State Health Commissioner has availed him-
self of the MSMS Syphilis Control Committee in seek-
ing advice towards the solution of questionable cases
connected with special certification for marri^e.

Similar problems of your patients will receive prompt
and careful consideration.

♦ ♦ ♦

The Michigan Society of Anesthetists was organized
May 22, 1941, in Ann Arbor. Joseph DePree, M.D.,
of Grand Rapids, was elected president ; Willis L.
Dixon, M.D., Grand Rapids, first vice president; R. J.
Himmelberger, M.D., Lansing, second vice president;
and Joseph C. Tiffany, M.D., of Grand Rapids, secre-
tary-treasurer.

Standing Committees on Education, Public Relations,
and Legislation were appointed. A committee is now
drawing up the Constitution and By-Laws.

Any anesthetists in Michigan who were not notified
of this organization are asked to contact Dr. Tiffany,
420 Metz Building, Grand Rapids.

/STRAINED VEGETABLES

MAGNIFIED 200 TIMES

LIBBY’S HOMOGENIZEDV
VEGETABLES A
magnified 200 TIMES

THESE PHOTOMICROGRAPHS demonstrate why
Libby’s exclusive process of special homogeniza-
tion makes vegetables and fruits easier to digest.
In the photomicrograph at the left, showing
strained vegetables, note the large cells, coarse
fibers, and closely packed starch granules. Com-
pare it with the photomicrograph of Libby’s spe-
cially homogenized Vegetables. Cells and fibers
are broken up, starch particles uniformly distrib-
uted, and nutriment released for easier digestion.

If you have never examined Libby’s Baby
Foods, we would like very much to send you a
sample can. As soon as you open it, you will
notice how much smoother and finer textured
Libby’s are. Libby, M9Neill & Libby, Chicago.

PEAS CARROTS SPINACH
VEGETABLE COMBINATIONS:

No. 1 — Pegs, Beets, Asparagus; No. 2 — Pumpkin,.

Tomato, Green Beans; No. 3 — Peas, Carrots, Spinach; No. 9
— Peas, Spinach, Green Beans; No. 10 — Tomato, Carrots, Peas

FRUIT COMBINATIONS: No. 5 — Prunes, Pineapple Juice,
Lemon Juice; No. 8 — Bananas, Apples, Apricots
CEREAL 2 SOUPS EVAPORATED MILK

ALSO Libby’s Chopped Foods for older babies (10 varieties)

556

DON'T FORGET YOUR GRAND RAPIDS

CONVENTION. SEPTEMBER 16. 17. 18. 19. 1941

In addition to the unusually attractive scien-
tific program arranged for your enjoyment (see
page 544 for names of the thirty nationally-known
out-of-Michigan lecturers), a number of spe-
cial events will feature the Grand Rapids Con-
vention.

A Smoker, for MSMS members only, has
been arranged for Thursday evening, September
18, 9:00 p.m., in the Ball Room of the Pantlind
Hotel. Complimentary admission card will be
sent to all members prior to the meeting.

Invitational Golf, at the beautiful Kent Country
Club, will be the highlight of Monday, September
15. Tee off at 1 :00 p.m. Dinner and presenta-
tion of prizes at the Club, 7 :00 p.m.

Special entertainment for the wives of visiting
physicians is being arranged by the Woman’s
Auxiliary.

Plan now to attend the 76th MSMS Conven-
tion. Combine a very pleasant vacation in Grand
Rapids with the opportunity to hear the nation’s
outstanding medical men discuss the latest ad-
vances in medical science. Upwards of 2,000
physicians are expected to register so hotel res-
ervations should be made immediately.

Say you saw it in the Journal of the Michigan State Medical Society

Jour. M.S.M.S.

COUNTY AND PERSONAL ACTIVITIES

j Industry Warned of Rejected Draftees

I Industry is facing a serious problem when it begins
to carry on with older men and rejected draftees, Dr.

I Kenneth E. Markuson, director of the Bureau of In-
I dustrial Hygiene of the State Health Department, de-
clared the other day.

Dr. Markuson spoke at the formal opening of the
; new medical building at Pontiac Motor Division. In
• his audience were 150 members of the Oakland County
Medical Society.

“Your greatest problem will not be increased produc-
tion, material shortages or strikes but the need for
more and more manpower,’’ Markuson told the Pontiac
physicians. “Young men have been drafted and indus-
try must fall back on older workers and the rejects of
. the Selective Service Act.

“In fairness to all, these new men should be given
! as stiff a physical examination as the Army gives.

This should be made before employment because these
I’ men are defective and should be placed where their
! defects are not a menace.

“The Army is rejecting 40 per cent of the draftees
and these men are going into industry.

“If they are not carefully examined there may be
disastrous results.”

Dr. C. D. Selby, medical consultant for General Mo-
tors, addressed Pontiac’s guests and told of the great
dependence of the plant physician on the outside prac-
titioner.

To prove his point he cited General Motors figures
for 187,000 hourly rated employes in 1940. These ^yere
22,521 who were disabled during the year for periods
in excess of seven days. Of these 1,395 were disabled
from occupational causes and 18,935 because of ordi-
nary" non-occupational diseases or injuries. Dr. Selby
said. The ratio of days lost “ivas one day for occupa-
tional disability to 300 days for nan-occupational.

Greatest source of time lost in 1940, Dr. Selby said,
was appendicitis in which 2,197 cases lost 101,174 days.
Influenza took 43,183 days and tonsillar infections
38,094 days.

TALKS ON SYPfflLIS CONTROL

Doctor, if you should be invited to speak be-
fore a county medical society or some other pro-
fessional group, or before a lay audience, on
“Syphilis Control,” the Syphilis Control Com-
mittee of the Michigan State Medical Society
invites you to utilize one of its sets of lantern
slides.

One set of slides has been developed for use
with professional groups, and another for lay
presentation. Accompanying the set is a sug-
gested outline for presentation in utilizing the
slides furnished under the auspices of the Com-
mittee. These slides have been carefully organ-
ized and are easy to present.

Write the Executive Office, 2020 Olds Tower,
Lansing, giving plenty of time for the slides to
be shipped to you. Indicate the date of your pres-
entation, the name of the organization and the
exact location to which you wish the slides sent.
There is no expense other than the cost of re-
turning slides by express to Lansing.

Civil Service examinations for medical technicians,
laboratory workers and nurses for hospitals and pub-
lic health nursing, have been announced. Appointments
are open for public health nursing consultant positions
paying $2,600 and $3,200 a year. This examination is
given only to registered graduate nurses who have com-
pleted a 4-year college course including or supplemented
by at least 1 year of study in public health nursing,
and who have had experience in public health nurs-

Formal opening of the new" Medical Building at Pontiac Motor Division
was featured by the visit of 150 members of the Oakland County Aledical
Society who toured the hospital and plant and dined as guests of the divi-
sion. A few of the visiting doctors are shown here in the hospital admitting
room.

July, 1941

557

COUNTY AND PERSONAL ACTIVITIES

PERFECTION

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(Medicated )

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(Medicated) is a safe, rational and up-to-
date applicator for the topical medication
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Each Tampon con-
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Glycerine q.s.

It is an individual applicator complete
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Moisture-resistant cord makes for easy re-
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PERECTION VAGINAL TAMPON
(A Hartz Laboratory Product) is the sim-
ple, convenient and modern Tampon that
you can depend on. Write or phone for
your supply today.

LABORATORY OF

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15 29 Broadway, Detroit . . Cherry 4600
PHARMACEUTICAL MANUFACTURERS • MEDICAL SUPPLIES

ing supervision. Applications will not be accepted after
July 26, 1941.

Applications will be accepted until further notice for
positions as medical technician paying from $1,620 to
$2,000 a year and as junior laboratory helper at $1,440.
To meet the pressing need for nurses in the Veterans’
Administration, Public Health Service and Indian Field
Service, the Commission has just reannounced the ex-
amination for Junior Graduate Nurse at $1,620 a year.
A written test is no longer required and the vision
requirements have been modified. Applications will be
rated as received until further notice. Persons who
are interested in and qualified for any of these po-
sitions are urged to send their applications to the
Commission’s Washington office.

WARNING!

All physicians who are in military service are
urged to formally cancel their narcotx licenses,
both state and federal. Otherwise, their names
will continue to be listed as active practitioners
and failure to renew may bring unnecessary pen-
alty. To be on the safe side, officially cancel your
license for narcotics.

Michigan Physicians on AMA Program

Michigan physicians on the program of the 1941
AMA Convention in Cleveland included the following:
Frank H. Bethell, M.D., Ann Arbor, on “Lymphatic
(Lymphogenous) Leukemia”; Howard C. Jackson, M.
D., and Frederick A. Coder, M.D., Ann Arbor, on
“The Use of Sulfanilamide in the Peritoneum” ; Nor-
man F. Miller, M.D., Ann Arbor, on “The Perpetua-

558

tion of Error in Obstetrics and Gynecology” ; A. C.
Furstenberg, M.D., Ann Arbor, on “Diseases of the
Salivary Glands” ; M. R. Kinde, M.D., Battle Creek, on
“Communicable Disease Control” ; Russell N. Dejong,
M.D., Ann Arbor, on “Vitamin E and Alpha-Tocopherol |
Tlierapy in Neuromuscular and Muscular Disorders”;
Reed M. Nesbit, M.D., and Wm. G. Gordon, M.D. of
Ann Arbor on “Surgical Treatment of the Autonomous
Neu"ogenic Bladder”; Carlisle F. Schroeder, M.D.,
Detroit, on “Presacral (Superior Hypogastric) Neurec-
tomy” ; Wm. Bromme, M.D., Detroit, on “The Chemo-
therapy of Gonorrheal Urethritis” ; “Charley J. Sm)4h,
IM.D., Richard H. Freyberg, M.D., and Isadore Lampe,
M.D., Ann Arbor, on “Roentgen Therapy for Rhizo-
melic Spondylitis” ; Louis J. Hirschman, M.D., Detroit,
on “The Colostomy Question” ; and C. C. Birkelo, M.
D., Detroit, on “The Roentgen Diagnosis of the Pri-
mary Tuberculous Infection.”

Penberthy- Weller Exhibit on Burns Wins
Silver Medal at Cleveland AMA

Grover C. Penberthy, M.D., and Charles N. Weller,

M. D., Detroit, won the Silver Medal in the Scientific
Exhibit of the American Medical Association at Cleve-
land. The exhibit illustrating the treatment of bums
was judged on the basis of excellence of presentation
and correlation of facts. Congratulations to Doctors
Penberthy and Weller !

Other Michigan physicians who won honors in Cleve-
land with their excellent scientific exhibits were Henry

N. Harkins, M.D., of Detroit, whose exhibit illustrated
the treatment of burn shock and Frank W. Hartman,
M.D., of Detroit for his exhibit on the development
of a method for the desiccation of human blood plasma.

Also participating in the scientific exhibit were the
following physicians from Michigan; George J. Curry,
M.D., Flint ; R. J. Noer, M.D., and James M. Win-

Tour. M.S.M.S.

Say you saw it in the Journal of the Michigan State Medical Society

COUNTY AND PERSONAL ACTIVITIES

field, M.D., of Detroit, demonstrating in the exhibit
on fractures ; Bernard A. Watson, M.D., Battle Creek

!■ on “Clinical Significance of Glycosuria and the Pre-
vention of Diabetes” ; Claire L. Straith, M.D., and
Wayne B. Slaughter, M.D., Detroit; and E. Hoyt De-
, Kleine, M.D., Buffalo, on “Plastic Surgery”^ Roy D.

I McClure, M.D., and Conrad R. Lam, M.D., Detroit, on
“Methods and Results in Heparin Administration” ;
and Lowell S. Selling, M.D., Detroit, on “Examination
I and Treatment of the Traffic Offender.”

Michigan’s Delegates Honored

I Henry A. Luce, M.D., Detroit, was named chairman
I of the important reference committee on Legislative
j and Public Relations of the AMA House of Delegates.

L. G. Christian, M.D., Lansing, was made a member
I of the reference committee on Reports of the Officers.
I Frank E. Reeder, M.D., Flint, was appointed Sergeant
I at Arms.

SUPPLEMENTARY ROSTER

The following members were certified to the Sec-
retary of the Michigan State Medical Society after
the Roster which appeared in the May and June is-
sues of The Journal had gone to press:

Genesee

Bruce, W. W Flint

Kaleta, Edward Flint

Gogebic

Eisele, D. C Ironwood

Reid, John D Ironwood

Grand Traverse-Leelanau-Benzie

Van Leuven, B. H Traverse City

Gratiot-Isabella-Clare

Carney, T. J

Hersee, W. E

Kilborn, H. F

Miller, S. W

Livingston

McGregor, A. J

Mecosta-Osceola-Lake

Peck, Louis

White, J. A

Oakland

Carr, W. H Holly

Christie, Edward Pontiac

St. Joseph

O’Dell, John H Three Rivers

Shaw, G. D Mendon

Weir, D. C Three Rivers

Wilkerson, Nina C Sturgis

Washtenaw

Adcock, John D Ann Arbor

Loder, Leonel Lewis Ann Arbor

Parsons, Robert J Ann Arbor

Simrall, James O. H Ann Arbor

Wayne

Alderman, R. F Detroit

Babcock, L. IC. ....................................... Detroit

Barnett, Louis L ! Detroit

Barone, Charles J Detroit

Bevington, Harry G Detroit

Bicknell, Nathan J Detroit

Blaine, Max Detroit

Bookmyer, Ralph H Detroit

Bookstein, Abraham M Detroit

Brachman D. S Detroit

Brown, Gordon T .! Detroit

Bruehle, Richard A .Detroit

Burnham, Frederick V !!!!. Detroit

Burrows, Howard A ..Detroit

July, 1941

!neA!l

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Black Label
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SOLE IMPORTER

Say vf*u saw it in the Journal of the Michigan State Medical Society

559

IN MEMORIAM

Ferguson -Droste- Ferguson Sanitarium

+

Ward S. Farguaon, M. D. Jamea C. Droste, M. O. Lynn A. Fergusont M. D.

*

PRACTICE LIMITED TO
DIAGNOSIS AND TREATMENT OF

DISEASES OF THE RECTUM

Sheldon Avenue at 02dce8

GRAND RAPIDS, MICHIGAN

+

Sanitarium Hotel Accommodations

Burstein, Harry S...
Burstein, I. Marvin.
Burstein, Morris M. .

Cameron, A. H

Carlson^ Harold W. .

Carlucci, Peter F

Carj^nte^ Glenn B. .

Collins, James B

Colvin, Leslie T

Crane, Langdon T. . .
Curhan, Joseph H. . .

Day, J. Claude

Dejongh, Edwin

Dillard, Malcolm
Drinkaus, Harold . . . .
Durham, Robert H. . .

Eaton, Crosby D

Fallis, Lawrence S. . .
Fenech, Harold B. . .
Fisher, George S....

Fog^t, Robert G

Fogt, Herbert E

Fordell, F. S

Friedman, I. H

Galdonyi, Nicholas...

Gates, Nathaniel

Gleason, John E

Gramley, Wm

Green, Ellis R

*Hanna, Carl

Hartman, Frank W. .
Henderson, Leslie T.
Hewitt, Robert S. . . .
Horkins, Harold A. .

Hunt, Verne G

Isaacson, Arthur . . .
Johnson, Ralph K. . . .

Kane, Alex M

Kates, Simon C

Kleinman, S

Koven, Abraham

Krebs, Wm. T

Krynicki, Francis X. .

Lance, Paul E

Levin, Michael M. . . .
Martin, Isaiah H. . . .
McClelland, Carl C. . .
Miller, Wm. E

Detroit

Detroit

Detroit

Wyandotte

Detroit

Detroit

Detroit

Detroit

Detroit

Detroit

Detroit

Detroit

Detroit

Detroit

Detroit

Detroit

Detroit

Detroit

Detroit

Detroit

Detroit

Detroit

Detroit

Detroit

Detroit

Detroit

Detroit

Detroit

Detroit

Camp Livingston, La.

Detroit

Detroit

Dearborn

Detroit

Detroit

Detroit

Detroit

Milwaukee

Detroit

Detroit

Detroit

Detroit

Detroit

Lapeer

Detroit

Detroit

Detroit

. . . .' Detroit

^Military service.

Moloney, J. Clark Detroit

Moroun, S. J Detroit

Mosee, W. Jones Detroit

Nickels, Albert W Detroit

Noer, Rudolf J Detroit

Norton, Arthur B Detroit

O’Brien, G. M Detroit

Orecklin, L Detroit

Pearman, Chas. L. R Detroit

Petix, Samuel C Detroit

Rieden, James A Detroit

Rom, Jack Detroit

Rosen, Robert Detroit

Seeley, James B Dearborn

Seiferlein, Archibald L Detroit

Shebesta, Bessey H Detroit

Sparks, J. H Detroit

Steffes, Everett M Detroit

Steiner, Louis J Detroit

Swanson, Carl Wm Detroit

Townsend. Kyle E Detroit

Watson, Douglas J Detroit

Weaver, Delmar F Detroit

Wood, Wilfred C Detroit

Wiechowski, Henry E Detroit

Za'k, Edward J Detroit

Jin jmemoriant

Earl S. Bullock of Detroit, was born in Detroit
in 1871 and was graduated from the Detroit College of
Medicine and Surgery in 1893. He served his intern-
ship at Harper Hospital and then became associated
with the late H. O. Walker, M.D. Doctor Bullock,
who specialized in tuberculosis, had his own Sanato-
rium in Silver City, New Mexico, for a number of
years. He returned to Detroit in 1926 and had been
associated with the Shurly Hospital since that year.
Doctor Bullock served his country overseas during the
World War. He died on May 1, 1941.

Jour. M.S.M.S.

560

Say you saw it in the Journal of the Michigan State Medical Society

THE DOCTOR’S LIBRARY

THE DOCTOR’S LIBRARY

Acknowledgment of all books received will he made in this
column and this will be deemed by us as a full compensation
of those sending them. A selection will be made for review,
as expedient.

PHYSICAL MEDICINE. The Employment of Physical
Agents for Diag^nosis and Therapy. By Frank H. Krusen,
M.D., F.A.C.P., Associate Professor of Physical Medicine,
the Mayo Foundation, University of Minnesota; Head of
the Section on Physical Therapy, the Mayo Clinic ; Member
of the Council on Physical Therapy of the American Medical
Association ; Past President of the American Congress of
Physical Therapy; Past President of The Academy of
Physical Medicine. With 351 illustrations. Philadelphia
and London: The W. B. Saunders Company, 1941. Price
$10.00.

Krusen is presenting here a most complete, yet
practical, compilation of physical therapy. After
some general chapters on the history, technique and
indications, he discusses in great detail with many in-
formative illustrations the technique, indications and
expectations for each of the forms of therapy used.
The varying claims are carefully and conservatively
evaluated providing a safe and efficient guide for the
general practitioner.

♦ !(: *

A TEXTBOOK OF OPHTHALMOLOGY. By Sanford R.
Gifford, M.A., M.D., F.A.C.S. Professor of Ophthalmology,
Northwestern University Medical School, Chicago ; Attend-
ing Ophthalmologist, Passavant Memorial and Cook County
Hospitals. Illustrated. Second Edition, Revised. Philadel-
phia and London: W. B. Saunders Company, 1941. Price:

$4.00.

While this is primarily a textbook it is sufficiently
practical to be of decided value to the general prac-

titioner. It is profusely illustrated and contains some
beautiful colored photographs which are well selected.
Its scope is broad and complete. The treatment is
well described and detailed to aid the physician.

S|! !)! *

TEXTBOOK OF PEDIATRICS. By T. P. Crozer Griffith,
MD., Ph.D., Emeritus Professor of Pediatrics in the Univer-
sity of Pennsylvania; Consulting Physician to the Children’s
Hospital, Philadelphia ; Consulting Physician to St. Christo-
pher's Hospital for Children ; Consulting Pediatrist to the
Woman’s, the Jewish, and the Misericordia Hospitals, etc. ;
Corresponding Member of the Societe de Pediatrie de Paris :
and A. Graeme Mitchell, M.D., B. K. Rachford Professor
of Pediatrics, College of Medicine, University of Cincinnati ;
Director of the Children’s Hospital Research Foundation;
Director of Pediatric_ and Cpntagious Services in the Cin-
cinnati General Hospital. Third Edition Revised and Reset.
Philadelphia and London : W. B. Saunders Company, 1941.
Price : $10.00.

This is the third edition of a textbook originally
published in 1933. It is encyclopedic in scope and
principally a textbook or a reference book for the
physician who seeks more information on a pediatric
subject. It is not profusely illustrated but the illustra-
tions are well chosen and explanatory. In the eight
years since the first publication this book has achieved
world-wide fame in its field. Griffith and Mitchell are
assisted by an imposing group of the leading pediatri-
cians and allied scientists of the continent. It is highly
recommended as a reference book.

4= ^ *

A MANUAL OF ALLERGY. ^ For General Practitioners.
By Milton B. Cohen, M.D., Director of The Asthma, Hay
Fever and Allergy Foundation; Visiting Physician in Allergy,
St. Alexis Hospital, Cleveland, Ohio. New York and Lon-
don; Paul B. Hoeber, Inc., Medical Book Department of
Harper and Brothers, 1941. Price: $2.00.

This is a pocket-sized volume of 156 pages in which
the broader and more practical aspects of allergic mani-
festations are covered for the use of the general prac-
titioner. While not neglecting a discussion of the

OR safety and reliability use composite Radon seeds in your
cases requiring interstitial radiation. The Composite Radon
Seed is the only type of metal Radon Seed having smooth,
round, non-cutting ends. In this type of seed, illustrated
here highly magnified. Radon is under gas-tight, leak-proof
seal. Composite Platinum (or Gold) Radon Seeds and
loading-slot instruments for their implantation are available
to you exclusively through us. Inquire and order by mail,
or preferably by telegraph, reversing charges.

THE RADIUM EMANATION CORPORATION

GRAYBAR BLDG. Telephone MO 4-6455 NEW YORK, N. Y.

July, 1941

Say you saw it in the Journal of the Michigan State Medical Society

561

THE DOCTOR’S LIBRARY

86c out of each $1.00 gross income
used for members benefit

PHYSiaANS CASUALTY ASSOCIATION
PHYSICIANS HEALTH ASSOCIATION

1 Hospital, Accident, Sickness ^

w insurance^

1^1 1*1 V

For ethical practitioners exclusively
(56,000 Policies in Force)

LIBERAL HOSPITAL EXPENSE
COVERAGE

For
$10.00
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$5,000.00 ACCIDENTAL DEATH

$25.00 weekly indemnity, accident and sickness

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$2,000,000.00 INVESTED ASSETS
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$200,000 deposited with State of Nebraska for pro-
tection of our members.

Disability need not be incurred in line of duty — benefits
from the beginning day of disability.

Send for applications, Doctor, to

400 First National Bank Building Omaha, Nebraska

PlKDriSSIOMAlPlIOTiaiOH

A DOCTOR SAYS;

“Your prompt response from the first
and evident concern for the protection
of our professional reputations as well
as our financial interests to the success-
ful termination of the case relieved us
of all worry.”

OF

theory of allergy, the pages are covered with usuable
material. The chapter ©n the physical examinations is
most interesting since the author discusses physical
findings which rnay corroborate a history of allergy.
One paragraph in his preface which is well worthy
of consideration : “*** Specialties in medicine and
specialists justify their existence only when they result
in better care for the sick ; further study by controlled
research to expand the frontiers of knowledge; and
better distribution of special knowledge to physicians
not familiar with the principles and methods employed
by workers in the specific fields.

“When judged by these standards, most medical spe-
cialties will be found to have made significant con-
tributions to the care of the sick and to research,
but f^ny have failed to hand down to the general
practitioners the seasoned generalizations which should
he part of every physician’s knowledge.***”

* * *

brucellosis (Undulant Fever) Clinical and Subclinical.
By Harold J. Harris, M.D., Health Officer, Westport, N. Y •
Consulting Physician, St. Lawrence State Hospital; Attend-
ing Physician, Elizabethtown Community Hospital ; Lieuten-
ant Commander, Medical Corps, United States Naval Re-
serve; Member, New York Academy of Medicine; Associate
Member, American College of Physicians. Foreword by
VV alter M. Simpson, M.D., F.A.C.P., Director, Kettering
Institute for Medical Research, Miami Valley Hospital, Day-
ton, Ohio. With 12 colored and 44 black-and-white illus-
trations. New York and London: Paul B. Hoeber, Inc.,

Medical Book Department of Harper and Brothers’ 194l’
Price: $5.50.

Doctor Harris, while practicing medic'ne in a rural
area of New York state, realized that he had failed to
recognize brucellosis in the early years of his practice
and became more and more stimulated to pursue stud-
ies in that field. This monograph is directed principal-
ly to the general practitioner whom he believes has the
first opportunity to recognize this serious menace to
public health. The clinical story of the disease is
simply but completely presented, the laboratory aspect
is properly evaluated and the prognosis and treatment
well covered. It is beautifully illustrated and the
typography is excellent. This book is recommended to
the progressive general practitioner.

* 4=

THE DOCTOR TAKES A HOLIDAY. An Autobiographical
Fragment. By Mary McKibbin-Harper, M.D. A bookfellow
Book. Cedar Rapids, Iowa: The Torch Press, 1941. Price'
$2.50.

Dr. Mary AIcKibbin-Harper has written a number of
travel books and in this account she describes her last
trip to the Orient. Her love for adventure, her inti-
mate acquaintances with the leading women physicians
and her flair for paragraph analyses make it indeed
interesting and cultural reading. Her debunking of
some of the impressions the occasional reader has of
the East is refreshing. Her description of the burial
in Bombay and its comparison to our past and present
burial customs is soul awakening. We can only hope
that in the author’s next book more use is made of the
interesting line drawings which infrequently impress
the reader more than word descriptions and less use
is made of references to visits with other women doc-
tors.

* * 4=

THE STORY OF CLINICAL PULMONARY TUBERCU-
LOSIS. By Lawrason Brown, M.D., Late Director of
Trudeau Sanatorium, Lecturer in Trudeau School of Tuber-
culosis ; Baltimore : The Williams and Wilkins Companv,

1941. Price: $2.75. '

To the physician interested in pulmonary tuberculosis,
and each physician should be, Lawrason Browm. one
of the best known specialists in the field has offered
an interesting, even thrilling history of the condition.
After reading this book one gains a clearer insight into
the superstitions and common beliefs held by a layman.
This is a very readable book which will stimulate the
medical mind.

562

Say you saw it in the Journal of the Michigan State Medical Society

Jour. M.S.M.S.

I

THE DOCTOR’S LIBRARY

DIETETICS FOR THE CLINICIAN. By Late Milton
Arlanden Bridges, B.S., M.D., F.A.C.P., Director of Medi-
! cine, Detention, Rikers Island and West Side Hospitals,
i New York; Consulting Physician, Seaview Hospital, Staten
Island, New York; and Department of Education, New York
University, New York; Assistant Professor of Clinical Medi-
; cine and Lecturer in Therapeutics and Nutrition, New York
' Post-Graduate Medical School of Columbia University; As-
sociate Attending Physician and Chief of Diagnostic Clinic,
i Post-Graduate Hospital, New York; Fellow of the New York
j Academy of Medicine. Fourth edition thoroughly revised,

j Philadelphia; Lea and Febiger, 1941. Price: $10.00.

I This is a posthumous book by one o£ the country’s
i leading clinicians who devoted most of his life to the
: study of the influence of food and disease. The sub-
j ject is exceptionally well covered and in its particular
field is encyclopedic. The major part of the volume is
devoted to the types of diet most suitable for various
I factors of diseases and extensive tables of contents
of various foods are included. These tables are ex-
! ceptionally complete and practically organized. The
book is recommended for any general practitioner.

4c 5): ^

I MACLEOD’S PHYSIOLOGY IN MODERN MEDICINE.

J Edited by Philip Bard, Professor of Physiology, Johns
I Hopkins University, School of Medicine, in collaboration with
nine authors. Ninth Edition. St. Louis : The C. V. Mosby
Company, 1941. Price: $10.00.

This book was originally published in 1918 by Pro-
fessor Macleod and received world renown as an
authoritative textbook and reference book of physiology.
In 1938, following the death of Macleod, Philip Bard
took over the editing of this text and with the assist-
ance of a group of the leading physiologists of the
United States has maintained the standards previously
set and has kept the volume in line with modern de-
velopments and acquisition of knowledge. This book is
primarily a textbook and reference book. The typogra-
phy is excellent and the illustrations are well selected.

4c jjc 4:

CARDIAC CLASSICS. A collection of Classic Works on the
Heart and Circulation with Comprehensive Biographic Ac-
counts of the Authors. Fifty-two Contributions by Fifty-one
Authors. By Frederick A. Willius, M.D., M.S. in Med.

; Chief, Section of Cardiology, The Mayo Clinic ; Professor of
i Medicine, The Mayo Foundation for Medical Education and
Research, the Graduate School, University of Minnesota : and
Thomas E. Keys, A.B., M.A., Reference Librarian, The
I Mayo Clinic; Formerly Carnegie Fellow, the Graduate
Library School, University of Chicago. St. Louis : The

C. V. Mosby Company, 1941. Price: $10.00.

This is a collection of original works on the heart
by the outstanding cardiologists of the modern world.
Beginning with Harvey’s dissertation on “The Circula-
tion of the Blood” the volume includes the translations
of the original work of fifty-one great cardiologists.
Together with these is appended a comprehensive bi-
ography of the authors. These biographies are indeed
interesting and the material presented would serve well
to orient any physician who is a student of the heart.

' The use of this collection of material should make
the best cardiologist better.

4s 4s 4:

MEDICAL DIAGNOSIS AND SYMPTOMATOLOGY. By
Samuel A. Ix>ewenberg, M.D., F.A.C.P., Clinical Profes-
sor of Medicine, Jefferson Medical College ; Assistant Phy-
sician to the Jefferson Hospital ; Consulting Physician to
the Philadelphia Hospital for Contagious Diseases and the
Philadelphia Psychiatric Hospital ; Visiting Physician to the
Philadelphia General Hospital, and the Northern Liberties
Hospital ; Formerly Assistant Professor of Physical Diag-
nosis at the Medico-Chirurgical College and the University of
Pennsylvania, Philadelphia. Fifth edition, entirely revised
and reset. Philadelphia; F. A. Davis Company, 1941.
Price $12.00

This is the fifth edition of a book originally published
in 1929 in which the author compiled a text^ok of
general information on medical diagnosis thus making
it a real general practitioner’s book. It is well illus-
trated and the arrangement is very practical. As a ref-
erence for the general practitioner it is recommended.
A chapter on special examinations is new and valuable.

July, 1941

DeNIKE

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starting September 8. Informal Course every week.

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Say you saw it in the Journal of the Michigan State Medical Society

563-

READING NOTICES

cfi^ective^, &mpement
and Sconottiical

The efifectiveness of Mercurochrome has been
demonstrated by twenty years’ extensive clinical use.

For the convenience of physicians Mercurochrome
is supplied in four forms — Aqueous Solution for
the treatment of wounds. Surgical Solution for
preoperative skin disinfection. Tablets and Powder
from which solutions of any desired concentration
may readily be prepared.

{dibrom-oxymercuri-fluorescein-sodiuin)

is economical because solutions may be dispensed
at low cost. Stock solutions keep indefinitely.

Mercurochrome is accepted by the
Council on Pharmacy and Chemistiy of
the American Medical Association.

Literature furnished on request

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BALTIMORE, MARYLAND

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Tetanus Immunization

The disadvantages and hazards of the temporary
passive immunity induced by tetanus antitoxin are well
known. A prolonged active immunity may now be
safely and satisfactorily produced by tetanus toxoid.
Several million soldier in France, England, Canada,
and Italy have received active immunization during the
past four years and to date no case of tetanus has
been reported (Mil. Surgeon, 88:371, 1941).

It is generally accepted that alum-precipitated tetanus
toxoid is a much more efficient antigen than plain tox-
oid. Once an individual has received immunization, a
stimulating or booster dose at any subsequent time
will markedly accelerate the serum antitoxin to a level
which will definitely protect from tetanus. Tetanus
toxoid is supplied by Eli Lilly and Company in the
alum-precipitated form.

New Searle Laboratories to Be Built at Skolde, 111.

G. D. Searle & Co., Chicago, announces that work
has been started on the building of its new laboratories
and pharmaceutical manufacturing plant located on the
outskirts of Chicago, in the Skokie district.

The contract calls for three stories and basement of
1,500, (XX) cubic feet. The exterior is to be a modern,
streamlined design with continuous windows protected
by projecting metal fins, which help to carry out the
streamline design.

The laboratory atmosphere is to be carried out
throughout the building, except in the auditorium,
which is designed not only for meetings of the staff
and workers, but for clinical meetings and demonstra-
tions to visiting physicians and interested medical
groups.

Rantex for Surgical Masks

The Holland-Rantos Company has been appointed ex-
clusive distributor for Rantex, the newest development
for surgical masks and caps — a patented fiber product
which is insoluble in live steam, boiling water or com-
mon solvents. A magnification of Rantex shows that it
is 176 times more protective than a single layer of
gauze. As a result, it provides masks and caps which
are exceptionally cool, comfortable, light and free from
irritating lint or yarn. They are inexpensive enough to
be discarded after a single use ; yet they can be auto-
claved or sterilized.

Sulfaguanidine, New Sulfonamide Derivative.

Is Released by Squibb

Sulfaguanidine, the new sulfonamide compound
which clinical trial indicates may be of great usefulness
in certain diseases of the gastro-intestinal tract, has
been released for sale by E. R. Squibb & Sons, New
York. It is supplied in 0.5 gram tablets, in bottles of
50, 100 and 1,0()0, and as a powder in 4-ounce and one-
pound bottles; also in 3.5 gram envelopes in packages
of 12.

Sulfaguanidine is distinguished from other sulfona-
mide derivatives by its low absorbability. This causes
it to remain in the intestinal tract and exert its anti-
bacterial influence therein. Consequently, it is useful

Jour. M.S.M.S.

564

Say you saw it in the Journal of the Michigan State Medical Society

READING NOTICES

in enteric infections, such as acute bacillary dysentery,
and also as a pre-operative and postoperative measure
in surgery of the lower intestinal tract.

Like the other sulfonamides, sulfaguanidine has high
antibacterial activity. Unlike them, and in spite of its
relative solubility in water, it diffuses to a much less
extent through the intestinal wall. It is, therefore,
possible to obtain a relatively high effective concen-
tration of the drug in the intestine itself (200 mg. per
cent) with little penetration into the circulation and
consequent systemic effects (1 to 4 mg. per cent con-
centration in the blood).

A tasteless drug, sulfaguanidine is administered
either in tablet form or as powder in water or similar
medium. Rather large doses appear to be required ;
even for children, but the total period of treatment
should not exceed 14 days. Recommended dosage and
methods of administration are described in the Squibb
leaflet on sulfaguanidine.

MAY THE OSTEOPATH DO SURGERY?

(Continued from Page 543)

a fundamental principle of a statutory construction that
the legislature must be presumed to have had in mind
all previous legislation upon the subject, so that in
the construction of a statute we must consider the pre-
existing law and any other acts relating to the same
subject. We, therefore, reach the conclusion that the
legislature has recognized obstetrics as a branch of
osteopathy, a conclusion which the court is obliged to
follow until the legislature by specific action evidences
a contrary view. We are, therefore, of the opinion,
after an examination of the legislative history of the
laws pertaining to osteopathy and their relation to
obstetrics and regulatory requirements as to reporting
childbirths, that the legislature has authorized a licensed
practitioner of osteopathy to engage in the practice of
obstetrics, and that the use of the word “physician”
in section 71-2404, Comp. St. 1929, was intended to in-
clude regularly licensed osteopathic physicians.

The attorney general contends that defendant is not
authorized tO' use anesthetics in his practice as an osteo-
path. The 1919 act of the legislature * * * provided
in part as follows: “Nothing in this act shall be con-
strued so as to authorize the administration, by an
osteopath, of drugs excepting anesthetics, antiseptics,
antidotes for poisons and narcotics for temporary re-
lief of suffering.” This clearly shows that the legisla-
ture intended the use of anesthetics to be included in
and authorized by the license to practice osteopathy.
In 1927 a new statute was enacted which read as fol-
lows : “Every license issued under this division shall
confer upon the holder thereof the right to practice
osteopathy in all its branches, as taught in the osteo-
pathic colleges recognized by the American Osteopathic
Association.” * * * We do not think the passage of
the 1927 act manifests any legislative intent to deprive
the defendant of his previously acquired privilege to
use anesthetics, antiseptics, antidotes for poisons, and
narcotics for temporary relief of suffering. We are
inclined to the view that when a legislative act grants
a privilege, as was done in the case at bar, a subsequent
enactment will not be construed to deprive a beneficiary
of the privilege conferred unless a legislative intent
to so do is clearly apparent from the legislation itself.
For these reasons, we hold that the defendant, under
the statutes as they now exist, is entitled to use anes-
thetics by virtue of his license to practice osteopathy.

The trial court erred in not granting an injunction
enjoining the defendant Gable from engaging in the prac-
tice of operative surgery and from publicly holding
himself out as licensed and otherwise qualified to per-
form operative surgery with surgical instruments. In
all other respects the judgment of the trial court is
correct.

Judgment accordingly.

Tuly, 1941

LABORATORY APPARATUS

Coors Porcelain
Pyrex Glassware
R. & B. Calibrated Ware
Chemical Thermometers
Hydrometers
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J. J. Baker & Co., C. P. Chemicals
Stains and Reagents
Standard Solutions

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Antitoxins • Media

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We are completely equipped and solicit
your inquiry for these lines as well as for
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Tissue Diagnosis
The Wassermann and Kahn Tests
.Blood Chemistry

Bacteriology and Clinical Pathology

Basal Metabolism

Aschheim-Zondek Pregnancy Test

Intravenous Therapy with rest rooms for
Patients.

Electrocardiograms

Central Laboratory

Oliver W. Lohr, M.D., Director

537 Millard St.

Saginaw

Phone, Dial 2-3893

The pathologist in direction is recognized
by the Council on Medical Education
and Hospitals of the A. M. A.

Say you saw it in the Journal of the Michigan State Medical Society

565

MISCELLANEOUS

DOCTOR'S CAR RANKS AS NEEDED
EQUIPMENT

Day and Night Emergency Calls Require Greater
Use of Car for Necessity Trips Than
Any Driver Group

In a profession that is no respecter of time-tables,
the physician’s car is just about as much a part of his
professional equipment as his stethoscope or ther-
mometer.

Because the hurry call to a patient’s home may come
at noon, midnight or dawn, the doctor must keep his
medical kit ready and his car on hand twenty-four
hours a day.

As a result, the medical man leads all occupational
groups in the number of round trips rolled up annually.

His speedometer also ticks off more total miles in
the course of a year than any other group, with the
sole exception of traveling salesmen.

Such statistical facts, gleaned from nationwide
study of the motor car’s use, cannot measure the
benefits to the sick and suffering which have resulted
from the swift mobility of the doctor’s car.

Residents of rural areaS, who had been far from a
doctor’s service in the horse-and-buggy days, are
especially aided.

Data on the car use show that the doctor’s automo-
bile is very much of a business vehicle. Nine out of
ten doctors who own automobiles use them in their
professional work. The great bulk of their trips are
concerned with transportation to and from the office,
and on professional rounds.

Out of every 100 doctors who use their private
automobiles for necessity transportation, it was found
that :

Sixteen average more than 1,500 trips annually.

Fifteen make from 1,000 to 1,500 trips per year.

Ten reported from 800 to 1,000 round trips by car
per year.

Twenty-eight range from 400 to 800 trips annually.

Twenty-two average from 200 to 400.

Only nine average fewer than 200 round trips a year
for necessity driving.

For all car-owning physicians, the average number
of round trips annually per car was found to be 947,
of which 842 trips or nearly 90 per cent of the total
were credited to necessity purposes.

Naturally, the length of the trips vary from a few
blocks to many miles, depending on the doctor’s loca-
tion and the range of his practice.

In rural areas, one half of the trips made by doctors
for business purposes average more than 15 miles in
length. In larger cities, four out of 10 physicians’ cars
average this distance or more. (As it is not unusual
for a doctor to make a series of calls on a single trip,
the city practitioner may cover a considerable distance
before returning to his office.)

Of all groups of car users, the doctors rank
next to the top, their average distance traveled in a
year being 12,932 miles per car. And according to
surveys, necessity driving accounted for 8,640 miles
of the total.

By comparison, traveling salesmen who lead the
occupational list of car users, have an average annual
mileage of 18,791 miles, though their number of
roundtrips are less.

The doctor’s annual total of 12,932 per car is more
than twice as high as the 5,750 miles rolled up bv
farmer-owned cars. And the use frequency of 94*7
round trips a year reported by the doctors is nearly
two and a half times the 392 trips averaged by the
farm car. Yet, on a percentage basis, 66 per cent of
the doctors’ mileage — and exactly the same figure for
farmers’ mileage — are for economic purposes.

The medical man uses his car nine times for neces-
sity transportation for every social and recreational
trip, though the latter is likely to be three or four
times longer. The average length of a pleasure trip
for doctors is about 40 miles, according to available

data, compared with a gen-
eral average of 10 miles per
trip for all necessity driv-
ing. But all of his social
and recreational driving
combined, adds up on the
average to only 4,292 miles
a year, less than a third of
his total.

Occupations which re-
quire high mileage and con-
stant use tend to have new'
or later model cars, as their
owners follow a practice of
trading frequently. Doctors
are in step with this prac-
tice. Survey figures show”^
that 89 per cent of doctor’s
cars were less than five
years of age and that 33
per cent were one year old
or less at the time of a
recent count. — Autonwhile
Facts, June, 1941.

THE MAPLES

A Private Sanitarium for the Treatment of Alcoholism

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Phone: High 6447

Located 2^ Miles East of Gotner on
U. S. 30 N.

F. P. Dirlam A. H. Nihizer, MJ>.

Superintendent Medical Director

566

Say you saw it in the Journal of the Michigan State Medical Society

Tour. M.S.M.S.

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August, 1941

Say you saio it in the .tournal of the Michigan State Medical Society

575

MICfflGAN MEDICAL SERVICE

The medical service plan movement- is becom-
ing fairly well established. California, Colorado,
Georgia, Idaho, Michigan, New Jersey, New
York,. Ohio, Washington, Oregon, Pennsylvania,
Wisconsin, Texas, Missouri, Massachusetts, New
Hampshire, West Virginia, Connecticut, and
Utah are some of the states in which the pro-
fessionally-sponsored movement is well under
way. At least twenty-five plans are in operation,
with a total enrollment in excess of 250,000 per-
sons. These programs offer a prepayment medi-
cal program to the public which is in accord with
sound professional principles as well as serving
to counteract those forces which tend to disrupt
the private practice of medicine.

The 1941 House of Delegates of the American
Medical Association, in considering this medical
service plan movement, took the following action :

“Your reference committee further recommends that
the House of Delegates reaffirm its belief that the prin-
ciple of prepaid medical care justifies an experimental
period during which time advice and assistance be
given to medical societies that elect to conduct such
experiments under medical sponsorship. It, therefore,
recommends special consideration and approval by the
House of this portion of the report.”!

The House of Delegates also adopted the rec-
ommendation of the reference committee that
the Board of Trustees take steps to see that the
Bureau of Medical' Economics is enabled to es-
tablish some method of coordination and inter-
change of data pertinent to the administration of
such plans in order that all state and county
medical societies may profit thereby.

Offset to Propaganda

lit is definitely recognized that the profession-
ally sponsored medical service programs are the
best offset to the tremendous propaganda by the
Committee on the Costs of Medical Care, the Na-
tional Health Survey of the United States Public
Health Service, the National Conference on
Medical Care, and the Committee on the Coordi-
nation of Health and Welfare Activities in the
United States.

Of even greater significance is the protection
which the medical service plan affords the pri-
vate practice of medicine against the inroads of
group clinic or lay controlled associations which

^Journal of the American Medical Association, June 21, 1941,
Volume 116, Number 25.

MICHIGAN MEDICAL SERVICE
REGISTRATION HONOR ROLL

(As of July 10, 1941)

100 per cent

Manistee

Mason

Mecosta-Osceola-Lake

Menomoninee

90 to 99 per cent
Bay-Arenac-Iosco
Calhoun
Gogebic

Grand Traverse-Leelanau-Benzie

Marquette-Alger

Oceana

St. Joseph

80 to 89 per cent

Allegan

Barry

Chippewa-Mackinac

Delta-Schoolcraft

Dickinson-Iron

Eaton

Gratiot-Isabella-Clare

Hillsdale

Houghton-Baraga-Keneenaw

Huron

Ingham

lonia-Montcalm

Kalamazoo

Kent

Lenawee

Livingston

Midland

Muskegon

Newaygo

Northern Michigan

Ontonagon

Ottawa

Saginaw

Tuscola

Wexford-Missaukee

75 to 79 per cent

Jackson

Macomb

Monroe

North Central Counties

Oakland

Wayne

parcel off the medical market to the few physi-
cians who are under contract to render services.
Such plans are nurtured by the Group Health
Federation of America, a national organization
which has already held its third annual meeting.

These plans, which restrict the individual pri-
vate practice of medicine, operate throughout the
United States and have obtained the patronage
of over 120,000 persons. The adverse decision in
(Continued on Page 578)

Jour. M.S.M.S.

576

D

D

Jl

[

i

X

Roentgenologists have acclaimed the Picker-Waite
"Century" to be a distinct achievement in shockproof
diagnostic x-ray equipment, st: It is a significant
fact that a greater number of "Century" units have
been bought by the medical profession than any
other similar x-ray apparatus.

With the "Century", fluoroscopic findings may be
recorded instantly and permanently by means of
the two-position Spot Film Attachment . . . increas-
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^ August, 1941

57?

Say you saw it in the Journal of the Michigan State Medical Society

MICHIGAN MEDICAL SERVICE

Main Entrance

SAWYER SAMTDRIUM
White Oaks Farm
Marian, Ohio

For the treatment of
Nervous and Mental Diseases
and Associated Conditions

Licensed for

The Treatment of Mental Diseases
by the Department of Public Welfare
Division of Mental Diseases
of the State of Ohio

Accredited by

The American College of Surgeons
Member of

The American Hospital Association
and

The Ohio Hospital Association

Housebook giving details, pictures,
and rates will be sent upon request.
Telephone 2140. Address,

SAWYER SAMTDRIUM

White Oaks Farm

Marion, Ohio

(Continued from Page 576)

the American Medical Association trial and the
sponsorship of the formation of such plans by
the Medical Economics Section of the Division
of Fiealth and Disability Studies, Bureau of Re-
search and Statistics, Social Security Board of
the Federal Security Agency will encourage the
organization of more of these plans.

Continuation of Private Practice

In those states where a medical service law
has been passed and the medical profession has
taken the lead in the formation of a voluntary
nonprofit prepayment program, there is real as-
surance that the private practice of medicine can
continue with ever-increasing opportunities to
render more adequate and a better quality of
medical service.

The increased good will of the public, of in-
dustry, of newspapers, and of the legislature,
which has been gained by the medical profession
in those states where medical service programs
have been inaugurated, alone justifies the wisdom
of entering into such an undertaking.

MSMS

COUNCIL AND COMMMITTEE MEETINGS

1. Friday and Saturday, July 11 and 12, 1941 — The
Council, Mackinac Island.

2. Friday, July 25, 1941 — Industrial Health Commit-
tee— Warded Hotel, Detroit — 6 :30 p.m.

■ MSMS

COUNTY MEDICAL SOCIETY MEETINGS

Berrien — Thursday, June 19 — Berrien Hills Country
Club — Speaker : Harriett Skemp Nystron, M.D., Chi-

cago, missionary physician, who discussed her adven-
tures encountered in foreign fields. Wednesday, July
16 — Niles — Speaker : Muir Clapper, M.D., Detroit —

Subject: “Differences in Diagnosis and Treatment of

Jaundice.”

Hillsdale — Thursday, July 24 — Hillsdale — Business
meeting to discuss recommendations of the Executive
Committee.

Ingham — Thursday, August 7 — Annual golf tourna-
ment held at Lansing Country Club.

Kent — Thursday, July 10, 1941 — Annual Doctor-Law-
yer picnic, Blythefield Country Club.

Muskegon — Friday, June 20 — Muskegon — Speaker:
Henry Cook, M.D., Flint — Subject : “Industrial Health

and the General Practitioner.”

Oakland — Wednesday, July 2 — Tillson’s Beach, Eliza-
beth Lake — Annual summer frolic.

MSMS

NEW COUNTY SOCIETY OFFICERS

Eaton County Medical Society

President — C. J. Sevener, M.D., Charlotte.

Vice President — Paul Engle, M.D., Olivet.

Secretary — B. P. Brown, M.D., Charlotte.

Treasurer— H. W. Hannah, M.D., Charlotte.

Delegate — Don V. Hargrave, M.D., Eaton Rapids.

Alternate Delegate — Paul Engle, M.D., Olivet.

Tout?. M.S.M.S.

578

Say you saw it in the Journal of the Michigan State Medical Society

Q. Are the proteins of canned meat of high biological value?

A. Oh yes. Canning does not influence the biological values
of proteins. And, of coiurse, the proteins of meats are
excellent sources of the essential amino acids. (1)

(1)

1939. Accepted Foods and Their Nutritional Significance, Council
on Foods of the American Medical Association, Chicago.

The Seal of Acceptance denotes that the nutri-
tional statements in this advertisement are accept-
able to the Council on Foods and Nutrition
of the American Medical Association.

AMERICAN CAN COMPANY

230 Park Avenue, New York, N. Y.

• •

Aik.ust, 1941

Say you saw it in the Journal of the Michigan State Medical Society

579

>f

HALF A CENTURY AGO

>f

ONE DAY WITH THE VILLAGE DOCTOR*

CHARLES S. COPE, M.D.

Ionia, Michigan

The general practitioner is a specialist in every de-
partment of medicine. He must be abreast of the
times and ever ready to treat promptly and successfully
every case that may present itself to his notice.

While the surgical pendulum is swinging far past
the center, on towards the limit of its vibration in the
unattainable, and every doctor now seeks to be a
surgeon of renown, and we are solicited on every hand
to notice the long list o'f successful operations being
performed daily by our brethren of the knife and saw,
it may prove refreshing to step aside from this grand
procession and, seeking the humble walks of profes-
sional life, to spend one day with the village doctor,
whose sole aim is to do good and who seeks neither
fame nor station. Let us go with him on his daily
rounds, notice his way of doing business, listen to the
instruction he gives his patients, and look over his
shoulder as he prescribes.

We may find some of his prescriptions worthy of
preservation, some of his methods worthy of adoption.

His first call is in the early morning. A messenger
in breathless haste announces that Mrs. K. had by mis-
take given 'the baby turpentine instead of castor oil.
While his hands are busy with a hasty toilet, his mind
is also busy, sweeping the broad avenues of materia
medica, where poisons and antidotes arise as appari-
tions at his command. As he takes down his medicine
case, we see the doctor take from the shelf a bottle
of olive oil. In a few moments he stands before his
patient, a child of six months. The mother had been
up with the child all night, as it had been suffering
for several days with a heavy cold and had grown
worse in the night. She at last had bethought herself
of the castor oil, and in seeking to give the child a
dose of this medicine, had by mistake filled her spoon
from a bottle of turpentine that stood in a similar
bottle on the same shelf. The quantities of phlegm
that had accumulated in the child’s throat and stomach
served to parry this heavy stroke inadvertently aimed
at its little life. There had been vomiting and most
of the turpentine thrown off, bu)t the burn and irrita-
tion remained. The mouth and throat were blistered,
and the babe in agony. It is given a half teaspoonful
of olive oil at once and this is repeated in five minutes,
and so- for half an hour vomiting continues from time
to time; but the oil is soothing, and with the burns
on the face and lips covered with a thick paste of
salaratus and water, the child grows easier and rests
quietly. Directions are left to give a half teaspoonful
of the oil every half hour till the bowels are moved
freely, when the child will be out of danger.

The followiing prescriptions are left for the mother’s
use in the further care of her child. For restlessness
and nervousness, the following prescription will be
found of great service. Containing neither opium nor
chloral, it can be given to the smallest child without
danger of serious consequence, and yet attended with
soothing, quieting results in every case:

•Read before the twenty-sixth annual meeting of the Michigan
State Medical Society, Saginaw, June, 1891.

580

Rx. Oil Anise, m xxv
Alcohol, oz. ij
FI. ext. valerian, oz. j
Ol. meth. pip. m. xv
Tr. camphor, dr. ij
FI. ext. licorice, oz. j. M.S.

Shake the bottle.

Dose — One-fourth to one-half teaspoonful in water;
repeat as needed.

For the cough, one grain muriate of ammonia in half
teaspoonful of glycerine, every three hours.

As the doctor steps into the street, he is hailed by a
clerk on his way to open his employer’s store, who says,
“I wish you would give me something for my cough.
It kept me awake nearly all night by a continued
tickling, and irritation in my throat. I don’t raise much,
but am sore all over from coughing so much.” The
following prescription is written:

Rx. Tict. opii, dr. j

FI. ext. lobeliae, dr. ss.

FI. ext. yerbae santae

FI. ext. grindeliae robustae, aa oz. ss.

Chloroform, c.p., dr. ss.

Syr. scillae comp., q.s., oz. ij. M.S.

Shake the bottle and keep well corked.

Dose — One drop on the tongue ; repeat every five
minutes, till the cough is better.

We are glad to see a bright half-dollar come out of
the clerk’s pocket and go into that of the doctor.

Passing on, he hears a great out-cry as he nears a
boarding house, and someone calls, “Run for the doctor,
quick;” but he is at hand and goes within. A child
had been playing near the stove while the breakfast was
in preparation, and had succeeded in depositing on its
abdomen part of the contents of a dish of hot gravy.
The result was a blister as large as a man’s hand,
extending from umbilicus to epigastrium ; child is two
years old. Its writhings are very similar to convul-
sions, its screams arousing every one in the house. The
doctor, cool and collected in that babel of confusion,
takes from the shelf an unbroken package of saleratus,
pours half of its contents into a tin wash dish, adds
enough water to this to make a thick paste, and covers
the burn with this mixture, making the application half
an inch thick. As soon as this is applied, the child
stops crying and is free from pain.. Leaving orders
to keep the child quiet all day, and not allow the soda
toi become dry for eight hours, he quietly leaves the
room. As he passes through the hall, a lady calls
from the stairway for him to come to room No. 9.
Here he finds a lady who had been confined three days
before, in whom the flowing had ceased for several
hours and she was suffering considerably. The nurse
had used injections and had exhausted her resources,
but to no purpose, and as there was a slight rise of
temperature, she fearedi puerperal infection and fever.
The doctor tells her to prepare a thick poultice of
pulverized anise-seed, and apply this to the vulva as
hot as could be borne, and renew when it becomes cold.
This will, in a few hours, have the desired effect.

A few hasty strides and he reaches his o^vn home,
(Continued on Page 582)

Jour. M.S. M.S.

m food (except breast milk) is more highly regarded
than Similac for feeding the very young, small twins,
prematures, or infants who have suffered a digestive upset.
Similac is satisfactory in these special cases simply because
it resembles breast milk so closely, and normal babies
thrive on it for the same reason. This similarity to breast
milk is definitely desirable — from birth until weaning.

A powdered, modified milk product es-
pecially prepared for infant feeding,
made from tuberculin tested cow’s milk
(casein modified) from which part of
the butter fat is removed and to which
has been added lactose, vegetable oils
and cod liver oil concentrate.

SIMIIAC 1

One level measure of the Similac pow-
der added to two ounces of water makes
2 fluid ounces of Similac. The caloric
value of the mixture is approximately
20 calories per fluid ounce.

August, 1941

Say you saw it in the Journal of the Michigan State Medical Society

HALF A CENTURY AGO

(Continued from Page 580)

where breakfast awaits him. It will be no breach of
etiquette to see of what he makes his morning meal.
Good bread and butter, rich milk, thick cream, fragrant
coffee, rolled oats eaten with butter and sugar, con-
stitute the repast. He is not made “loggy” by meat,
noT dyspeptic by pastry, but with his stomach filled
with easily digested nutritious food, he goes about his
work not realizing that he has such an appendage as
a digestive apparatus.

Immediately after breakfast, in accordance with a
fixed and proper habit, the promptings of nature are
heeded. The wisdom of the maxim : “Always trust in
God, andl keep your bowels open,” is manifest in the
life and works of our friend.

The bell of the telephone has been jingling some
little time, when he lowers the trumpet and notes
down the calls that come from distant points.

With elastic step he reaches the home of his first
patient, a lady of 60 years, who is thin and nervous,
anaemic and dyspeptic; habitually constipated; subject
to severe and frequent headaches. Her diet is mostly
bread, potatoes, and tea; she has a weak, irregular
heart; pulse jerky and intermittent. For this condi-
tion of the heart she is ordered to take, night and
morning, 10 drops of the fluid extract of cactus gran di-
flora. From the words of praise that come to the
doctor every day in regard to this “heart medicine,”
he is encouraged to continue its use. As an aid to
the digestion, she is given a prescription for extract of
malt, with pepsin and pancreatin, to be taken in tea-
spoonful doses, with meals.

If the useful effects of malt were better understood
by the profession it would be more largel}' used tlian
it now is. As a tonic she is given this prescription :

Rx. N. F. 370, oz. vj.

Sig. — One teaspoonful before each meal.

This is almost the same as Fellows’ Syr. of the
Hypophosphites. It can be prepared by the local drug-
gist. Every physician and every druggist should have
a copy of a book of formulae, published by the Ameri-
can Pharmaceutical Association, known as the National
Formulary. From this the doctor has received many
useful suggestions in prescribing, and made many
friends by reason of the palatable prescriptions that he
has found in this collection of formulae.

The next case is one of chills and fever in a child of
12 months. It needs a cathartic and it needs quinine.

For the first is written :

Rx. N. F. 382, oz. jv.

Sig.. — One teaspoonful twice daily till bowels are regulated.

This is the Comp. Syr. O'f Senna, containing senna,
rhubarb and frangula, and is an admirable laxative for
children.

The prescription for the chills is as follows :

Rx. Quinine Sulph., dr. j.

N. F. 54, oz. jv. M. S.

Sig.- — One teaspoonful every three hours.

This is made from yerba santa and is a complete
mask for bitter tastes. Children take this and cry for
more. The physician who uses this will have many
friends among the children, and the praises of the
mothers as well.

Word is brought that a child had fallen from a tree
and broken an elbow. On examination a fracture of
irmer condyle of humerus, with partial dislocation of
elbow with angular deformity is discovered. By ma-
nipulation, the fracture is adjusted and the dislocation
reduced. Cold application is made to the joint by
first wrapping it in flannel and around this is passed
several coils of small rubber hose. One end of the
hose is secured within a large pail beneath the couch.
By siphoning the water through this tube the local

action of cold is applied to the joint without the
annoyance of wet clothing that would result from the
application of water or ice applied directly to the parts.
By proper use of this, the swelling and pain that so
frequently attend such injuries can be very effectually
controlled.

But what is most interesting to us in this case is the
very peculiar splint the doctor provides for this in-
jury. It looks as though it was made of cloth, but on
handling it, it is found to be as hard as a board.

The way this is made is as follows : Dissolve by

aid of heat one pound of gum shellac and one ounce of
borax in a pint of best alcohol. Cut from heavy cloth
the size and shape needed, perforate or make pores by
means of a shoe punch, if desired. Also render anti-
septic, if need be.

Now on this cloth spread a thick layer of this shellac
mixture. Dry it quickly into the cloth in an oven, or
before a hot fire. When it is all taken up by the cloth,
add another layer of shellac and heat it in ; repeat this
till the meshes of the goods are filled. It is now ready
for use. Warm the splint so as to make it easily bent,
and then apply gently to the injury. By careful han-
dling it can be moulded to any joint at any angle, even
if swollen and painful. After moulding gently to the
parts, it takes an impression distinctly of every pro-
tuberance and depression. In a few moments it sets
or hardens into an immovable splint. It is now taken
off, as it but encircles one half or two-thirds of the
posterior surface of the joint; being lined with thin,
absorbent cotton, it is replaced, and a light roller
bandage applied to hold the splint in place. The sleeve
(ripped in the seam at the wrist) is pulled down over
the splint, and with a large safety pin made fast to the
clothing over the breast of the child. When we find
that the bandage, splint, and sling are completed and
thus adjusted, the child can walk about at pleasure
without danger of harm to the joint. When necessan,'
the splint can be removed and passive motion of the
joint made. As swelling subsides, or, if necessary,
changes in angle of flexure are made, they can be ac-
commodated by warming the splint and moulding it to
the limb in its new position and reapplying. This form
of splint will be found useful in fracture of the lower
jaw.

The next case is one of “the Grip.” Temperature
103°; respirations 36; pulse 60; headache intense —
head feels as big as a barn ; can’t take a long breath ;
short, dry cough ; lungs congested ; pain in legs and
back ; frequent desire to void scanty, high-colored
urine ; bowels constipated ; tongue coated heavily,
with deep red transverse cracks ; great thirst ; nothing
tastes good. Patient is a man of 30 j-ears. The
doctor places on the patient’s tongue a tablet containing
1-50 gr. nitro-glycerine. In a few moments it dissolves,
and is absorbed. The feeling of largeness of the head
is intensified for a few moments, and then rapidly
vanishes; the breathing becomes easier; this remedy
often acting like magic in dispelling lung congestions.
He is now given 25 grains of calomel and 10-grains of
acetanilid, at one dose, to be followed in four hours
with a Seidlitz powder ; Seidlitz powders to be re-
peated every two hours till the bowels move freely.
Acids and cold drinks strictly forbidden for 24 hours.
Hot milk in teacupful doses ordered every three hours.
As long as fever and headache continue, 5 grains of
acetanilid are to be taken every fourth hour; alter-
nating with this, 5 drops of fl. ext. gelsemium are to be
given in water, and continued until the action of the
kidneys becomes normal. Before leaving the patient,
the doctor puts 10 drops of the tincture of nux vomica
into a glass of water, saying, “Stir this well, and give
him a teaspoonful every hour, if he has pain or sore-
ness in the bowels following the action of his cathartic.’'

As he passes through the hall, he is asked by a
domestic in Ithe family, to prescribe for her. She is a
(Continued on Page 584)

Jour. M.S.M.S.

582

PATHOLOGY OF THE UPPER RESPIRATORY TRACT

(Above) Allergic Rhinitis

(Below) Five Minutes after application of Neo-Synephrin Hydrochloride

ALLERGIC

RHINITIS

In allergic rhinitis, relief
from nasal congestion is the
thing the patient urgently de-
mands— the single criterion by
which he evaluates treatment.

To bring such relief

DOSAGE FORMS

Emulsion (1-oz. bottle with
dropper)

Solution H% and 1% in saline
solution (1-oz. bottles)
H% in Ringer’s Solution
with Aromatics (1-oz.
bottles)

Jelly M% (in collapsible tubes
with nasal applicator)

NEO-SYNEPHRIN HYDROCHLORIDE

Gaevo-alpha-hydroxy-beta-methyl-amino-3 hydroxy ethylbenzene hydrochloride)

shrinks the nasal mucous membrane swiftly — with more pro-
longed effect than ephedrine, and with lower toxicity in thera-
peutic dosage.

There is no “sting” on application, and unpleasant side re-
actions are a rarity.

EMULSION

SOLUTION

JELLY

FREDERICK STEARHS & COMPANY, Detroit, Michigaii

New York Kansas City San Francisco Windsor, Ontario Sydney, Australia

August, 1941

Say you sazv it in the Journal of the Michigan State Medical Society

583

HALF A CENTURY AGO

(Continued from Page 582)
large woman, of Bohemian descent, about 40 years of
age, the mother of one child, now about 16 years old.
She complains of a lump in her breast, that is sore and
painful to the touch. It has been growing for several
months, but she refrained! from calling a doctor for fear
she would be told it was cancer. When first noticed it
was not as large as the end of her little finger ; it is
now as large as her thumb. The pain is of a sharp,
stinging kind, paroxysmal in character. She can’t bear
her clothing to touch it, and has been obliged to' leave
off her corset for a long time. The shoulder and arm
is lame, and she has some pain under the arm. The
doctor finds, on examination, a hard, movable, sensitive
tumor, deeply imbedded in the right mammary gland,
an inch to the upper and outer side of the nipple.
The following is ordered: One drop of the fluid ext.
of poke root (phytolacca decandra), to be taken three
times a day. If we could see this case in three months,
we would find the lameness of shoulder and arm_ all
gone; the tumor reduced more than half; its sensitive-
ness abolished; the pain from axilla removed. She is
wearing her corset again, and able to pursue her work
as usual. By continued use of this remedy the docto'r
has removed many tumors from the breasts of ladies
who must otherwise have had to resort to the knife of
the surgeon.

A c.all comes from a row of tenement houses, where
the sanitary surroundings are bad. Here are three
children, less than a year old, all suffering from
entero-colitis ; vomiting, purging, restless, moaning,
high fever ; back of head very hot ; outlook is bad.
Step near and see what is done. Calling for a glass of
water that had previously been boiled, he places therein
a tablet containing 1-100 gr. of the arsenite of copper.
When dissolved, a teaspoonful is given to each child ;
this dose is repeated every ten minutes for an hour;
after this one dose every hour till the bowels are
better. This remedy is destined to take an important
place in the treatment of enteric troubles, both acute
and chronic bowel troubles yielding to its influence in
these ridiculously small doses. But why should we
question this, when we are prescribing Fowler’s solution
in drop doses, or bichloride of mercury, 2 grains to a
quart of water, as a sure germicide? For the fever in
these cases, one half drop tr. aconite every two hours.
For heat in back of head, 5 grains of bromide of potas-
sium every fourth hour. For weakness and prostration,
5 drops of brandy every half-hour. Careful directions
as to diet, nothing allowed but Swiss condensed milk
(as they are all fed artificially) ; no water allowed but
that which has been previously boiled. To sweeten the
air of the rooms and tO' render wholesome the atmos-
phere of the vicinity, Platt’s chlorides are ordered to be
used freely all over the premises.

But other cases need attention. Here is a child with
capillary bronchitis and a double inguinal hernia. Child
is 5 months old. Every effort at coughing only makes
the already distended scrotum more prominent. A
flax-seed meal poultice is at once placed around the
child, completely enveloping the chest from chin to
stomach, held high in place by straps over the shoulders,
the pattern for the poultice cloth being one of the
child’s dress waists, cut so that it comes up well under
the arms. Without especial care, nearly every such
poultice is placed on a child, assumes the form of a
circingle, acting as a cold damp zone around the body,
and is found on examination to be resting snugly on
the abdomen. But made thin and properly applied, and
secured, then covered outside with warm flannel, it
proves a source of comfort, and a curative agent. Far
the fever, one-'fourth drop tincture of aconite is to be
given in water every hour. For coughing the follow-
ing:

Rx. Ammon, carb. dr. j.

Glycerin.

Syr. bals. tolut. aa oz. ij. M. S.

Half teaspoonful every two hours.

In passing, we note that, in every prescription for
children, the doctor uses glycerine in place of simple
syrup, as it prevents rather than produces acid fermen-
tation in the stomachs of children. Brandy is given in
5-drop doses every hour till better. The hernia next
requires attention. Careful taxis is made. The head
and shoulders meanwhile being lowered by lifting the
feet and limbs to an angle of 45° to 90°, inverting the
body, and allowing the force of gravity to carry the
bowels far within the abdominal cavity; the hands of
the doctor are placed over the inguinal rings and held
there till the following simple but effective truss is
applied : To a flarmel band, long enough to pass once
and a-half around the child, and about 5 inches in
width, are fastened two square bags of unbleached
muslin, filled with fine sand. These bags are inches
square, and serve as the pads of the truss. Between the
pads and the skin a thin layer of absorbent cotton is
interposed ; then, when all is in place, draw snug and
fasten with safety pins. An elastic tape can be secured
before and behind, passing between the thighs. This
completes a simple and complete device for the treat-
ment of inguinal hernia in children. Instructions are
given to keep this truss constantly on the child for two
years, never allowing the bowels to protrude; care
also being used to prevent chafing. In the hands of a
mother of common sense this will prove a success every
time, as the doctor has often demonstrated.

It is now far past the noon hour. The people where
he is, give him a dirmer of roast meat, potatoes with
gravy, water for drink, rice pudding for dessert, with
fruits. A few moments are spent over the daily papers
and he is away again to see a patient who lives at some
distance.

This is in the factory district, where quite a clinic
awaits him.

A child has a large glass bead up its nose, and quite
a crowd of women are assembled. The doctor places
the boy on a chair with head well thrown back, and the
mother is told to place her mouth over the child’s
mouth and to blow as hard as she can, the doctor hold-
ing his finger on the nose so as to completely close the
nostril opposite the side where the bead is. After some
demurring on the part of the boy and hesitaucy of the
mother, the attempt is made and fails; but on finding
that the bead is nearer the outlet of the nose she tries
again, and the bead goes bounding over the floor, while
the mother seeks a handkerchief to remove the debris
from her face.

A storm of applause follows, and when it subsides
several women come to the doctor for advice. A
young mother says : “I wish you would give me some-
thing for my baby. I can’t say that he is sick, but he
worries all the time and I can’t do anything with him.
He won’t nurse, and yet he seems hungry all the time,
but the moment he takes the nipple he pushes it away
and cries.” The baby is carefully examined and handed

“Madam, you are to blow into this child’s mouth and
clear out the nostrils, just as this lady blew the bead
from her boy’s nose. The nose is filled up away back
where you could not reach it with your hairpin.” After
some nervous hesitation on the part of the mother, the
trial is made and quite a quantity of mucus bloum out.
This is repeated several times, when the child is given
the breast, and, seizing it with all the avidity of
starvation, takes its fill of nourishment, not letting go
till it falls asleep.

Another woman presents her baby. It has a cold and
a very hard cough that the cough medicines fail to !
relieve. The cough is loose, but the paroxysms were j
violent and exhausting when they occurred. The s^e
plan of clearing the air passages is advised and tried,
as the child is beginning to cough. When the air pas- '
sages were thus cleared, the coughing ceased. This ^vas
caused by the catarrhal accumulations dropping back ,
into the throat and exciting cough by tickling and
(Comthmed on Page 586)

Jour. M.S.M.S.

584

idvertisements

setter tomorrow, 1 n

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late to prevent a ser.ous dines

gam the advantage of t.memtrea

already contracted. ^

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in your household? Stomach^

is sometimes the

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„-Hch may be precous. '

Call vour doctor, and let hvn

or not ’the ailment is trivial a

, j„.«Wit.Heknows-y

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If he were back in

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and he’d show up for w
But in this man’s A
who feels below par
•'Sick Call,” even
much wrong. Private
obeying orders.

Because of this wi:
“Sick Call,” our Arm;
tunity to combat lU
and are usually abh
I edging over into the
1 of the reasons why

I our Army of 1941
I In this there is a '
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ork as usual.

,rmy of ours, a soldier
is required to report for
if he thinks there’s nothing
Tom Smith is simp 5

coMP-ii^y

who permits
to run risks
take. 'We’re
If I don’t feel

August, 1941

Say you saw it in the Journal of the Michigan State Medical Society

585

HALF A CENTURY AGO

(Continued from Page 584)
irritation in the pharynx. She is advised to watch the
child and, when it begins coughing, to clear out the
air passages in this way, and that she will accomplish
more than by cough medicines. The doctor is heard to
remark: “If physicians, nurses, and mothers only knew
how much comfort they would aflford the children under
their care by this simple procedure, they would adopit
it at once.”

Another woman says : “My boy had the croup last
night, and we are afraid he will have it again tonight.
Can’t you give something to keep it off?”

The following is written:

Rx. Quinine sulph., gr. xxxij.

N. F. 54, oz. j. M. S.

Shake the bottle.

Give one teaspoonful at 4 p.m. and one teaspoonful at
8 p.m. each evening till better.

Four grains of quinine at a dose as above, will, in
most cases, abort a case of ordinary croup.

A young lady comes to the doctor and says, in a
whisper: “I want something to restore my voice, as I
am to take part in a church concert tomorrow.”

She is given:

Carb. ammon., gr. j.

Chlorate potass., gr. v.

Sacch. alb., gr. xx.

Aldose this^size to be taken every hour till better.

Another miss, whose face is covered with cornedones
and erythematous eruptions, asks for help. She is given
Fowler’s solution— ordered to take one drop after each
meal for a month. After removing the blackheads by
pressure, she is to bathe the face three times daily with
the best C. P. Peroxide of Hydrogen.

And here is a young man who has had to lay off
because “he has so many boils.

One teaspoonful of tincture of arnica is put in a
tumbler of water with directions to take one teaspoonful
every hour. He is also given one dozen 2-grain pills of
sulphide of calcium, with directions to take one after
each meal till he can taste rotten eggs. ^

And here is a case of sore eyes. They say : He has

wildhairs” (whatever that may mean). Examination
reveals a severe conjunctivitis, the result of a cold and
exposure. Order a tablespoonful of Epsom salts in half
a glass of water to be taken at once; repeat every
second day till better. In a clean earthen dish one half
drachm of boracic acid is placed and dissolved in a
pint of hot water. He is ordered to sit by this bowl
and to make constant and continued applications of this
hot water for half a day at a time, and to continue this
till the redness is all gone, and to keep the water hot
all the time.

Again the doctor talks to himself, and we hear him
say: “If people only knew how much good is to be
derived from water, both hot and cold, there would be
a less number of calls for the rnedical man.”

But he has not long to moralize, for an emergency
has arisen that will tax him severely. He is called to a
child that has had convulsions, and has now been in a
fit for an hour. The ladies in attendance have had it in
a hot water bath, with cold to the head, for nearly that
length of time, and yet it relaxes not, but rigid and
stiff, seems in articulo mortis. It takes but a moment
to apply to its nostrils a bottle of amyl nitrite, an
inhalation or two relaxes the spasm, and now the
chloroform is used as an inhalant. The child is
ordered to be removed from the bath, wiped dry, and
wrapped in warm flannels. The doctor calls for a long,
stiff feather, and with this he clears out the phlegm and
accumulations in the throat. The jaws are pried apart,
and held so by a lead pencil beltween the molars. The
feather is pushed down the throat and twisted slowly
round and then removed, wiped and returned, and this
repeated many times to clear out the passages and to

excite vomiting, if possible. And now 25 grains of
sulphate of zinc, in a teaspoonful of warm water, is
forced down the throat. The rapid whirling of the
feather is again introduced into the throat to assist the
efforts of vomiting, and soon the contents of the stomach
are ejected, the spasmodic action removed, and the
child assumes a natural composure and quietly falls
asleep. Leaving orders for perfect rest and quietude,
for the next six hours, the doctor takes his leave.

By this time it is past sunset, and on reaching home
he finds a bowl of bread and milk (which is his
simple repast at night) awaiting him. When this is
partaken of, he spends an hour in his study with the
medical journals. These read through or glanced at,
his quick eye catches from a page just the best grains
and seed thoughts, he turns to his accounts and from
weariness nods over the ledger. In a moment he rouses
and seeks his couch, and there we leave him, wrapped
in the embraces of “Tired Nature’s sweet restorer,
balmy sleep.”

In Lansing

HOTEL OLDS

Fireproof

400 ROOMS

^|^i4ZZ worth while laboratory exam-
inations; including — ■

Tissue Diagnosis

The Wassermann and Kahn Tests

Blood Chemistry

Bacteriology and Clinical Pathology

Basal Metabolism

Aschheim-Zondek Pregnancy Test

Intravenous Therapy with rest rooms for
Patients.

Electrocardiograms

Central Laboratory

Oliver W. Lohr, M.D., Director

537 Millard St.

Saginaw

Phone, Dial 2-3893

The pathologist in direction is recop^nized
by the Council on Medical Education
and Hospitals of the A. M. A.

586

Jour. M.S.M.S.

TK£ journal

of the Michigan State Medical Society

Issued Monthly Under the Direction of the Council

Volume 40

August, 1941

Number 8

The Surgical Dyspepsias

By Ambrose L. Lockwood, D.S.O., M.C., M.D.,
C.M., F.A.C.S., F.R.C.S.(C)

Lockwood Clinic, Toronto, Canada

Ambrose L. Lockwood, M.D.

M.D., McGill University, 1910. Spent
several years in postgraduate luork in
New York, London and Germany.
Caught in Berlin at outbreak of the
Great War — escaped and joined the
Royal Army Medical Corps and served
as a surgical specialist with them five
years. Awarded the D.S.O., M.C., the
Mons Star, and was three times men-
tioned in dispatches. After the war he
returned to Mayo Clinic^ and was on
the Surgical Staff there till the summer
of 1922, when he established his own
Clinic in Toronto. Has published nu-
merous treatises in the field of Thoracic
and General Surgery, and has recently
published an exhaustive summary of
his experiences in War Surgery through
the British Medical Journal. Member
Canadian Medical Association, Ontario
Medical Association, American Associa-
tion for the Study of Goiter, and the
Society of Military Surgeons.

■ Space will not permit me to enlarge on the
role that focal infection in teeth, tonsils and
sinuses play in the etiology of dyspepsia.

Expert roentgenology and closer cooperation
among all members of the profession in the study
of disease have revealed serious conditions, hith-
erto overlooked, which serve to perplex the pro-
fession in determining etiology, symptomatology
and methods necessary for relief of symptoms
indiscriminately referred to as the dyspepsias.

Esophageal Diverticula

May I at once direct your attention to esopha-
geal diverticula, not an altogether uncommon
problem, and yet overlooked for seven and a half
years in a large collected group of cases. The
symptoms point directly to the condition, and it
can be so accurately diagnosed roentgenologically,
and so easily dealt with surgically by a one or
two-stage surgical procedure under local anes-

thesia. Because of the loss of weight, the cough
and mucus it has in the past been most com-
monly diagnosed as tuberculosis (Figs. 1 and 2).

Cancer and Stricture of the Esophagus

I shall merely point out that an ever-increasing
number of successful resections of the esophagus
are being reported. Earlier diagnosis will mate-
rially extend the field of operability. The relief
afforded by early gastrostomy in carcinoma of
the esophagus should be kept in mind.

Cardiospasm

Cardiospasm is another all too common condi-
tion, overlooked also for about eight years on
the average, and here again the symptoms point
directly to the lesion, and it likewise can be easily
diagnosed roentgenologically and at least 75 per
cent can be cured by dilatation with the hydro-
static dilator (Plummer), a relatively simple
procedure, with practically no mortality, and af-
fording an almost miraculous cure. Twelve per
cent require several dilatations to effect a cure,
and the remaining 13 per cent develop a “lag,”
and of these at least one-half are ultimately cured
by periodic dilatations. The condition is too often
diagnosed as cholecystitis, gastritis, or neurosis
as illustrated by the following case.

A young married woman, aged thirty-four, had com-
plained since fourteen years of age of ifficulty in swal-
lowing, regurgitation of food and mucus, foul breath,
distaste for food, and loss of weight, strength and en-
ergy. She had a dilatation with relief at seventeen years
of age — not again until twenty-six years of age, and not
again until a few months ago. Now, unfortunately,
after all these years she has developed an enormous
sigmoid type of cardiospasm. From the roentgeno-
grams you can judge the tremendous amount of foul
decayed food she had retained in the great saccula-
tion that had resulted from the prolonged atresia at
the cardia. She was emaciated, had a profotmd anemia,
a constant, distressing cough with a great deal of
foul mucous, and had been diagnosed at first as a
neurosis and latterly as tuberculosis. After nearly three
weeks of daily lavages the esophagus ^vas finally suf-
ficiently clear of retained food to permit the passage

593

August, 1941

THE SURGICAL DYSPEPSIAS— LOCKWOOD

of a linen thread through the cardia, the stomach, and
into the intestine. She was dilated with great care,
and with no little difficulty under direct fluoroscopic
vision. She has had three subsequent dilatations,
gained weight and feels that she is cured, but she

symptoms, while more indefinite than those of
esophageal diverticula and cardiospasm, are fair-
ly clear cut, and do point direct to the condition.

Fig. 1. Fig. 2.

may require esophagogastrostomy for complete relief
as, unfortunately, so many of the sigmoid type of car-
diospasm require. However, she has such marked
dilatation and sacculation that the operation, in experi-
enced hands, should not be particularly difficult, and
entails a relatively low operative risk. It is indeed dif-
ficult to understand how such a condition could possibly
be overlooked for such a long period (Figs. 3, 4
and 5).

Operative measures devised for the cure of
ordinary atresia are no longer warranted, and
should not be employed. They carry too high
a mortality and the results of even a successful
operation are incomplete and uncertain. Further
investigation as to etiology is necessary, and earl-
ier recognition is imperative.

Diaphragmatic Hernia

This is another all too common condition that
we have all overlooked until very recently.

Prior to 1925 a relatively few cases had been
diagnosed during life, and a very small percen-
tage of these had been dealt with surgical-
ly 1,2,4,5,6,10,12 since 1925, 600 cases have been
diagnosed, and 260 operated upon — 74 per cent
of these occurred through the esophageal hiatus.

The symptoms are referred to the epigastrium,
and a little to the left of the mid-line. The

Epigastric distress with regurgitation of gas, sour
fluid or food, periodic vomiting, bloating, difficul-
ty in belching of gas at times, paroxysms of
smothering, occurring immediately after eating,
and occasionally hemoptysis and melena sug-
gest the presence of a herniation through the
diaphragm, and warrant immediate roentgenol-
ogical examination. One negative roentgenologi-
cal finding is not sufficient in the presence of
such a history as the organ or organs are not
always incarcerated in the hernia. The symp-
toms, of course, vary with the organ or organs
involved in the hernia, and whether incarcerated
or not, and the extent of such incarceration.
While in approximately 74 per cent the cardiac
end of the stomach herniates through the eso-
phageal hiatus or adjacent to it, the colon, the
spleen, and even small bowel may be involved.

Cholecystitis and peptic ulcer with obstruction
at the pylorus are the most common errors in
diagnosis, and a very high percentage of such pa-
tients have been operated upon for these condi-
tions, of course without relief.

Mrs. S., No. 105004, aged forty-two, a dentist’s wife,
had had three major operations for relief of symptoms
without any benefit over a period of four years, and

Jour. M.S.M.S.

594

THE SURGICAL DYSPEPSIAS— LOCKWOOD

yet the condition was not sought for even at operation.
She had had the symptoms since fourteen years of
age. Her complaints were typical — roentgenological
examination revealed more than half the stomach her-
niated through the esophageal hiatus. She was imme-

In the differential diagnosis of the “Surgical
Dyspepsias” one must have in mind certain con-
ditions that frequently contribute to the picture

diately relieved by operation under a block anesthesia,
but the procedure was not made easier as a result of
the adhesions remaining from the three previous opera-
tions. In addition, it required no little tact and per-
suasion to avoid a judicial procedure against the former
surgeon for loss of time, suffering and distress inciden-
tal to three major surgical procedures, and for remu-
neration for the heavy expenses entailed (Pig. 6).

Such a case illustrates the wisdom and indeed
the necessity of sweeping the hand over the dia-
phragm and particularly the esophageal hiatus in
the course of all operations in which the abdomen
is opened. Exploration at operation has fre-
quently revealed the condition when it was not
otherwise suspected. If the esophageal hiatus
will readily admit two fingers the possibility of
periodic herniation of the stomach through the
hiatus must be kept in mind.

Treatment. — Treatment should be medical if
distress is not too great and obstruction is not
constant. If incarceration is maintained with
constant distress and recurring symptoms due
to obstruction, surgery should be advised. The
presence of peptic ulcer, cholecystitis or appendi-
citis must be kept in mind, and dealt with at the
time if at all possible. The operative procedure
for relief of diaphragmatic hernia is not tech-
nically difficult if adequate exposure is ensured,
with experienced assistants, and under a select
anesthesia. Surgeons undertaking the procedure
for the first time should study the method de-
veloped by Harrington who has dealt so success-
fully with such a large number of cases.

Fig. 6.

and serve to cloud the recognition of an as-
sociated surgical basis for the indigestion, viz. :
hepatitis, cirrhosis, hyper- and hypochlorhydria,
syphilis of the stomach, tabetic crisis, angina, ab-
dominis, abdominal migraine, Henoch’s purpura,
abdominal angioneurotic edema, intestinal and
pulmonary'- tuberculosis, Bright’s disease, per-
nicious anemia, lead poisoning, acute and chronic
pelvic infection, occasionally uterine fibroids and
ovarian and parovarian cysts, spastic and cathar-
tic colitis and the functional dyspepsias. These
and gastric disturbances incidental to certain
respiratory and circulatory diseases, faulty kid-
ney elimination, acidosis, altered metabolism, neu-
roses, psychoneurosis, anemias, environment,
phlegmatic temperament and disregard of the

August, 1941

595

THE SURGICAL DYSPEPSIAS— LOCKWOOD

esthetics of life must be considered but are be-
yond the scope of this address.

Intra-abdominal Conditions

In passing on to the more common and direct
causes of surgical dyspepsia, may one point out
that the stomach is the mouthpiece for a host of
other organs. The duodenum, when alkaline,
has the paramount right over the stomach in con-
trol of the pylorus, and this control is possessed
to a variable extent by the derivatives of the
mid-gut down to the splenic flexure of the colon,
and accounts for gastric distress in intestinal
disease.

Lesions of the intestinal tract from the pylorus
to the splenic flexure may cause gastric symptoms
as a result of pylorospasm, to prevent food pass-
ing through the pylorus into the bowel. As a
result, the emptying of the stomach is retarded,
digestive functions are interfered with, fermenta-
tion and secretory changes occur, and symptoms
of dyspepsia appear.

The fundus of the stomach is a later develop-
ment, and so more under the control of the
central nervous system. A feeling of repletion
after meals, fullness, bloating and such subjec-
tive symptoms develop. There probably is
no complaint of gastric distress without ob-
struction. Obstruction itself may be due to
reflex spasms, to direct pressure and blockage
from within or without.

The more common direct causes of dyspepsia
amenable to surgery are first those outside the
stomach as — appendicitis, gall-bladder disease, le-
sions of the pancreas, tumors, cysts, herniae,
Pott’s disease, and perhaps aneurysm, and sec-
ondly, those occurring in the stomach and bowel,
viz. : ulcer — tumors — benign and malignant, di-
verticula and diverticulitis, linitis plastica, syphi-
lis of the stomach, and gastro j ej unal ulcer.

The space at my disposal will not permit me
to deal at length with all the more direct causes
of surgical dyspepsia, but very briefly —

Pancreas

Lesions of the pancreas, especially acute and
chronic pancreatitis, should be readily recognized.
The severity of the pain, abdominal rigidity, in-
tense epigastric tenderness, vomiting, ileus, shock,
in fact all the symptoms of acute intestinal ob-

struction without obstruction should point to
acute pancreatitis. Cysts of the organ, ade-
nomata, carcinoma and stone in the pancreatic
duct must be kept in mind. An ever-increasing
number of patients with cysts and tumors of the
pancreas are being successfully dealt with surgi-
cally. Care must be taken, however, not to give
surgery a black eye in forcing a wide resection
for carcinoma which may not extend life a day,
and may have a fatal termination on the operat-
ing table or within the next few days.

Hemiae

Inguinal, postoperative, umbilical and ventral
hemise, particularly with a loop of bowel or more
often an impacted portion of omentum may, by
traction and obstruction cause atypical upper ab-
dominal distress, and should be sought for.

Meckel’s Diverticulum

The incidence of Meckel’s diverticulum should
be kept in mind and the fact that retention, ulcer-
ation, perforation, hemorrhage, traction, and even
malignancy are associated with it, and in all
indeterminate dyspepsias it should be ruled out.

Acute but particularly chronic intussusception
must be kept in mind. The latter is commonly
overlooked for a long period of years.

Appendix

The role of the appendix, the gall bladder
and ducts scarcely need to be enlarged on as a
cause of surgical dyspepsia. I am, however,
sufficiently old-fashioned to believe that chron-
ic appendicitis does exist, that it accounts for a
high percentage of patients with typical pyloro-
spasm and particularly accounts for persisting
pylorospasm after surgical procedures on the
duodenum, gall bladder and even the stomach
when, for one reason or another, the appendix
has not been removed.

Gall Bladder

As regards the gall bladder and liver ducts,
I believe too much credence is placed in the
roentgenograms .

Roentgenograms of the gall bladder are of
great value, but ONLY when POSITIVE.

It should be kept in mind that disease of the
gall bladder is four times as common in women
as in men, that jaundice is absent in nearly 40

Jour. M.S.M.S.

596

. _ • ; ‘ ' - - >• ■ L< ■ t v-av</^!ai_

THE SURGICAL DYSPEPSIAS— LOCKWOOD

m per cent of patients with stones even in the
* ducts, that at least 20 per cent never have had
colic, that stones may be present for years in

the gall bladder, and even the ducts and yet be
completely silent; that carcinoma of the gall
bladder is not rare and is usually associated whth
stones ; that in almost 25 per cent of patients with
stones in the gall bladder the ducts should be
likewise explored at operation, and finally that
patients with gall bladder disease not relieved by
medical regime should be dealt with surgically
and not continued on s}Tnptomatic treatment till
the pancreas and heart are involved, malignancy
develops, or a major catastrophe occurs wfith a
stone impacted in the ducts, or an acute gangre-
nous gall bladder, possibly with perforation.

Stomach

Syphilis of the stomach presents a group of
symptoms more diverse than any other disease
of the organ. The average age incidence, thirt}*-
eight years, is younger than for carcinoma. The
general condition of the patient is better than
in those with malignancy. Achylia occurs in a
higher percentage, approximately 80 per cent as
against 46 per cent in carcinoma. There is sel-
dom a palpable tumor, no filling defect, and
rarerly retention. The response to antileutic
treatment is rapid, and is a most valuable thera-
peutic test. It is not a surgical problem.

Linitis Plastica

This, a most interesting condition, is still over-
looked, and few patients present themselves early

enough to justify radical resection. Life has
been prolonged and in greater comfort by a very
high resection.

Carcinoma and Ulcer

Ulcer, carcinoma and hour-glass contracture
present a group of symptoms that usually make
roentgenologic examination imperative. Exhaus-
tive diffemtial analysis of the symptoms associ-
ated with these lesions does not enter the scope
of this paper.

Suffice it to point out that ulcers are of three
types: First, those that are benign and re-

main benign, those that are benign and be-
come malignant, and those that are malignant
from the onset. Expert roentgenologists can,
as a rule, recognize a malignant ulcer, but they
cannot, with any degree of accuracy, diagnose
an ulcer as benign. Great care should be taken
prescribing medical regime for a patient with
gastric ulcer, lest valuable time be lost and the
opportunity for a complete surgical cure lost.
All of us have seen very painful instances of
such an error. If medical treatment is insti-
tuted and the ulcer does not promptly re-
spond to treatment as proven roentgenologi-
cally, surgery should not be delayed (Fig. 7).

August, 1941

597

THE SURGICAL DYSPEPSIAS— LOCKWOOD

The Balfour cautery excision with suture and
posterior gastro-enterostomy is the operation of
choice for small, well localized benign ulcers and

reinforcing suture of heavy silk. The patient
can be up and about on the second postoperative
day, and leave the hospital quite safely on the

Pig. 8.

a gastric resection of the Polya-Balfour type or
anterocolic type for the more extensive lesions
(Figs. 8 and 9).

As regards carcinoma of the stomach, we must
keep it constantly in mind that one-third of all
cancers in men and one-fifth in women occur
in the stomach; that approximately 11 per cent
are silent and rarely diagnosed till too late to
effect a surgical cure ; that in not more than
50 per cent are we justified in even exploring
the abdomen, and that less than half of these
can be resected with a fair chance of materially
prolonging life, much less securing a complete
cure.

Complete gastrectomy is being employed in
an ever-increasing number of late cases, and
even in the presence of glandular involvement
and localized metastasis in the liver, should
be carried out. This procedure, at first sight
a heroic one, will, I believe, in skilled and
experienced hands prove to carry little, if any,
greater mortality than the more conservative
resections.

I should like to urge in all questionable cases
that the exploration should be carried out under
local anesthesia, and if further surgery is im-
possible, that the incision should be closed with

Fig. 9.

third or fourth day. In this way, prolonged hos-
pitalization is reduced, expense avoided, and a
higher percentage of patients will not hesitate to
permit of what appear<s to the patient, relatives
and friends as a trivial procedure.

Diagnosis. — Fatigue for no obvious reason, dis-
taste for food, especially meat, and a vague whit-
ish-lemon tint to the skin are the earliest symp-
toms, but, unfortunately, frequently the growth
is already too wide-spread to permit of a cure.
Only by routine examinations of all patients over
thirty years of age every ten months, with pe-
riodic gastric roentgenological examination will
carcinoma of the stomach be recognized su-
ficiently early to permit of a higher percentage of
surgical cures. The value of roentgenological
examination in the diagnosis of carcinoma of the
stomach, makes it important and necessary to
develop the simplest, most economical and time-
saving method of gastric and duodenal roent-
genologic study, if an increasingly large percen-
tage of patients are going to avail themselves of
it. Carman’s method of fluoroscopic examina-
tion with two or three films for record purposes
is all that is necessary, and takes but a few
minutes of the patient’s time. Taking innumer-
able films, and bringing the patient back time
after time for four to six days to follow the

598

Jour. M.S.M.S.

THE SURGICAL DYSPEPSIAS— LOCKWOOD

barium, demands so much of the patient’s time,
and creates such needless expense that patients
will not submit to frequent periodic check-ups

loric sphincter
Duodenum

FIr. 10.

Fig. 12.

8 per cent. A higher percentage of periodic
health examinations, including periodic gastro-
intestinal roentgenological examinations, thorough

Ist. row.

Fig. 13.

or recommend it to their friends, and, besides, pre-operative preparation, and resection in the

little if any additional evidence is found by hands of an experienced surgeon dealing with

such a time- wasting and expensive method of the condition daily will effect a much higher per-
examination. Gastric resection, even gastrectomy, centage of cures in this altogether too common
should not entail a mortality of more than 4 to and serious condition.

August, 1941

599

THE SURGICAL DYSPEPSIAS— LOCKWOOD

Duodenal Ulcer

Space does not permit me to deal at length
with this most important problem either from a
diagnostic point of view or in a review of the
various measures employed surgically to circum-
vent the lesion. It is on the increase affecting
approximately 13 per cent of the white collar
population. It is one of the great crippling dis-
eases of our time. Many conditions simulate
duodenal ulcer, but a duodenal ulcer simulates
nothing else. The periodicity of the symptoms,
the pain — food — ease syndrome point to the le-
sion, and it can be diagnosed roentgenologically
with 97.3 per cent accuracy. There has been a
deplorable tendency on this continent in the last
fifteen years to resort to medical measures, diet,
mucin, Larostidine, and what not, for too long
a period, and to defer surgery till a major catas-
trophe occurs due to obstruction, a penetrating
lesion, perforation, or a fatal hemorrhage. One
reason for this has been the unfortunate and
unwarranted tendency in this country to advise
and practice extensive gastric resection for the
condition. The procedure was based, on the ex-
periences of certain central European surgeons.
This was a gross error. Nearly thirty years
ago I recognized that duodenal ulcer in central
Europe was an entirely different entity from
that I had seen on this continent. There it is
associated with a widespread gastritis that is not
seen in this country, except in central European
races segregated in our large cities. In such
patients high resection is the operation of choice,
as it is for those with recurrent bleeding and
wide-spread ulceration, extreme stenosis and
peri-duodenitis and obstruction with marked hy-
peracidity, in which instances we have employed
it for more than twenty years (Figs. 10-13).

The Finney and particularly the Judd type
of pyloroplasty, designed to remove the ulcer and
at least four-fifths of the pyloric valve and
reconstruct the normal alignment of the duode-
num and stomach is much less difficult to execute,
entails almost no mortality, avoids the risk of a
gastrojejunal ulcer, and does not bum all our
bridges as in gastric resection, and leaves with
us several alternatives should an ulcer recur,
which is very rare. The Von Haberer opera-
tion and Horsley method are valuable in selected
cases, and that long, well-established procedure,
posterior gastro-enterostomy remains the opera-

tion of choice in a very definite percentage of pa-
tients.

Gastric Diverticulum

Gastric Diverticulum is a rare condition, but
must not be overlooked; about 150 cases have
been reported in the literature. The majority
have been found on the posterior wall of the
stomach, close to the lesser curvature, and with
about equal frequency at the pylorus, and at
the cardia. Diverticulum has rarely been re-
ported on the greater curvature or on the an-
terior wall of the stomach. The symptoms are
largely those of gastric ulcer, and the diagnosis
depends on fluoroscopic examination. Roentgen-
ologists who rely on multiple films will miss a
high percentage of gastric diverticula as they
likewise frequently miss a deeply pitted adherent
ulcer on the posterior wall. The inherent ten-
dency of irritative lesions of the stomach to
develop malignancy, and the fact that many
instances of carcinoma developing from the
border of a diverticulum have been reported,
make it imperative to deal surgically with the
diverticulum if it can be readily approached. Re-
tention is common and hemorrhage occurs. Diet-
ary and medical regime gives some relief.

Duodenal Diverticula

It is still necessary to stress the necessity of
searching for duodenal diverticula in all patients
with vague and atypical upper abdominal dis-
tress. While, for many years, diverticulum of
the esophagus, the bladder and Meckel’s divertic-
ulum has been recognized and dealt with surgi-
cally, duodenal diverticulum, an equally distress-
ing condition, occurring more frequently has
been relatively overlooked all these years as a
surgical entity.

Prior to 1912, approximately 100 cases had
been reported, all discovered accidentally at oper-
ation for some other condition or at necropsy.
In 1913, Case,® then at Battle Creek, was the
first to recognize the condition roentgenologically
and reported four cases. As late as 1920, in a
review of the literature, he found only eighty
cases so diagnosed. Neil John MacLean® of
Winnipeg in 1923 reported sixteen cases, of
which four were dealt with surgically. In 1924,
NageP^ of the Mayo Clinic reported 140 cases,
discovered at operation or necropsy, four of
which were operated upon. In our own Clinic

Jour. M.S.M.S.

600

THE SURGICAL DYSPEPSIAS— LOCKWOOD

ninety-seven cases have been diagnosed roent-
genologically, and thirty-eight of these have been
dealt with surgically. An exhaustive review of

or without bleeding, perforation or retention ex-
ists, and of course the nature of the foods in-
gested. The pain occurs soon after eating, is

Fig. 14.

Fig. 16.

Stomach

reported cases shows an incidence of 2.2 per
cent of routine necropsies. We have found them
in approximately 1.7 per cent of routine gastro-
intestinal roentgenological examinations.

Space will not permit me to deal at length with
the etiology, pathology, symptoms, relative sites
and complications of this interesting condition.
They are congenital in origin. In 60 per cent of
our cases the diverticulum occurred on the inner
border of the second part of the duodenum, 30
per cent in the third part, and only 10 per cent
in the first part of the duodenum, and so must
not be conflicted with pouching in the base of a
healing duodenal ulcer found almost entirely in
the first part of the duodenum close up to the
pylorus. Of our cases only two occurred on the
outer curvature of the bowel, and only one on
the anterior surface. All were retroperitoneal
except this latter one. They vary in size from 1
cm. in diameter to one that contained over 1,000
c.c. of fluid and hung down over the grim of the
pelvis as reported by Pilcher. They occur at any
age, but are more common in patients past the
fourth decade.

Diagnosis. — The symptoms are fairly clear cut
( and point to the condition. Patients complain of
;• pain and deep tenderness usually a little to the
K left of the mid-line, above the navel about op-
, posite the ninth costal cartilage. It varies in
; type and intensity, depending on the site of the
^ diverticulum, the size of it, the diameter of the
opening into it, whether or not ulceration with

often severe and spasmodic, often of a bursting
type, and associated with a sense of fullness and
distension locally, but not with bloating, as seen
in cholecystitis. Deep soreness and tenderness
frequently transmitted through to the back ex-
ists in large diverticula particularly if there is
ulceration and marked retention due to a narrow
opening and a long drawn-out neck leading into
the sac. A narrow neck measuring 3 to 5 cm.
in length was found at operation in several of our
cases. The pain and soreness was present over
a period of years in our patients. There is no
periodicity in the symptoms, no periods of well-
being as with duodenal ulcer. The pain — food —
ease syndrome of duodenal ulcer does not exist.
The pain is relieved by belching of gas and the
taking of soda, but usually more completely by
vomiting, which is very frequently induced. Pa-
tients dread food and avoid it, and as a result
most patients have lost considerable weight, are
anemic, generally debilitated, and develop that
distressing mental outlook that characterizes pa-
tients who have for a long time been unable to
eat types of food they enjoy. While the symp-
toms suggest the condition, expert and painstak-
ing fluoroscopic examination must be relied on
for accurate diagnosis and localization of the sac.
They take a bizarre form. There may be a wide
opening into the sac, a narrow opening or as
previously pointed out a small opening, with a
neck leading to a sac that is cylindrical in outline
or irregular. They may be multiple. Bleeding is
not rare and ulceration and perforation of the

August, 1941

601

THE SURGICAL DYSPEPSIAS— LOCKWOOD

sac does occur. We have had one perforate into
the gall bladder, and later into the colon in a
man of sixty-five years of age while on rigid
medical regime, with a near catastrophe as can
well be imagined.

Treatment. — The treatment should be surgical
if distress persists in spite of adequate dietary
regime. Surgical treatment consists in dissecting
and freeing the sac; the neck of the sac is crush-
ed in a curved forcep, ligated, the sac severed,
and the pedicle then oversewn and buried. If the
sac is not easily located in the first or second
part of the duodenum, the duodenum should be
incised, a finger inserted, the opening into the
sac located from within and the finger passed
into the diverticulum if the opening and the neck
of the sac is sufficiently large to permit it. This
method simplifies the freeing of the sac from its
attachments. If a duodenal ulcer is present as
well, and particularly if the sac has dissected and
embedded itself too deeply in the pancreas, it
is wiser to rely on a gastro-enterostomy to relieve
the distress rather than injure the pancreas or
unduly extend the operation in attempting to
dissect out the sac as well (Figs 14, 15, 16).

A diverticulum in the second portion of the
duodenum comes off the upper border of the
bowel, retroperitoneally, and drops down behind
the bowel. It can readily be exposed by elevating
the transverse colon and mesocolon, and by mak-
ing a small opening at the reflection of the peri-
toneum posteriorly, one comes directly on the
duodenum. The sac should then be dissected
free from above, delivered up and removed.
Drainage is unnecessary.

Patients are at once relived of their complaints
by surgical treatment. In the thirty-eight pa-
tients operated upon we have had no deaths, post-
operative complications or recurrences of the di-
verticula. Is it strange or difficult to believe,
that when we find patients with such distress
from a duodenal ulcer, that we should likewise
find patients with distress from a duodenal di-
verticulum in which retention, ulceration, hemor-
rhage, and even perforation occurs ? I crave your
indulgence for stressing the question of duodenal
diverticulum, but I am convinced by experience
that there is a definite percentage of patients with
upper abdominal distress, a truly surgical dyspep-
sia, due tO' duodenal diverticulum, that is being
constantly overlooked in the roentgenological
examination of the duodenum.

Conclusions

1. Greater accuracy in the diagnosis of
diseases of the gastro-intestinal tract have re-
vealed serious conditions overlooked hitherto and
has materially increased the problems that per-
plex the profession in determining the cause,
course, symptoms and measures for relief of
symptoms vaguely referred to as the “dys-
pepsias.”

2. There has been during the last twenty years
an ever decreasing mortality in dealing surgically
with the surgical dyspepsias.

3. Earlier and more accurate diagnosis ;
thorough rehabilitation of the patient prior to
operation in the greater use of glucose, calcium,
various vitamins and particularly blood trans-
fusion; a select anesthesia, preferably I believe
spinal (Pontocaine) with adequate pre-operative
sedatives and perhaps intravenous injections ; dis-
patch at the operating table, and multiple stage
operations when indicated have collectively con-
tributed to the successful surgical treatment of
the causes of surgical dyspepsia.

Finally and equally important is the urgent
necessity of educating the public to the wisdom
of periodic examination, and the profession to
the importance of a careful, detailed history,
thorough laboratory investigation, and above all
expert, time-saving and relatively inexpensive
roentgenological examination of all patients with
even the faintest symptoms of so-called surgical
dyspepsia.

References

1. Arnsparger; Quoted by Unger, A. S., and Speiser, M. D.:
Congenital diaphragmatic hernia: Seven cases with autopsies.
Am. Jour. Roentgenol., 15:135-143, (Feb.) 1926.

2. Carman, Russell D., and Fineman, S.: Roentgenologic

diagnosis of diaphragmatic hernia. Radiology, 3 :26-4S,
(July) 1924.

3. Case, J. T. : Diverticula of small intestine, other than
Meckel’s diverticulum. Jour. A.M.A., 75:1463-1470, (Nov.
27) 1920.

4. Giffin, H. Z. : The diagnosis of diaphragmatic hernia.

Ann. Surg., 4:388-389, 1912.

5. Harrington, S. W. : Surgical treatment of 105 cases of
diaphragmatic hernia. West. Jour. Surg., 44:225-269, (May)
1936.

6. Kienboeck, R. : Uber Magengeschwure bei Hernia und

Eventratio Diaphragmatica, Fortschr. a. d. Geb. d. Rdntgen-
strahlen, 21:322, 1913-1914.

7. Lockwood, A. L. : Diverticula of stomach and small intestine.
Jour. A.M.A.. 98:961-964, (Mar. 19) 1932.

8. McQuay, R. W. : Duodenal diverticula and their surgical
treatment. Surg., (Jan.) 1929.

9. MacLean, N. J. : Diverticulum of the duodenum, with re-
port of case in which the diverticulum was imbedded in
the head of pancreas, and a method for its removal. Surg.,
(Jynec. and Obst., 37:6-13, (July) 1923.

10. Morrison, L. B. : Diaphragmatic hernia of fundus of

stomach through the esophageal hiatus. Jour. A.M.A., 84:
161-163, (Jan. 17) 1925.

11. Nagel, G. W. : Unusual conditions in the duodenum and
their significance. Collected Papers of the Mayo Clinic,
16:90, 1924.

12. Rowlands, E. R. B. : A case of diaphragmatic hernia.

Guy’s Hosp. Gaz., 34:426, 1920; Diaphragmatic hernia.
Guy’s Hosp. Rep., 71:91-101, 1921.

602

Jour. M.S.M.S.

XANTHOMA OF THE TONGUE— LAMBERSON

Xanthoma of the Tongue

A Case Report

By Frank A. Lamberson, M.D.

Detroit, Michigan

Frank A. Lamberson, M.D.

B.S. in Medicine, University of Michigan,

1933. M.D., University of Michigan, 1935.

Licentiate of the American Board of Otolaryn-
gology, June, 1940. Staff member of Mount
Carmel Mercy Hospital, Detroit, Department
of Otolaryngology. Member Michigan State
Medical Society.

■ A XANTHOMA is not a rare tumor. It is most
commonly seen associated with diabetes and in
those cases in connection with the long muscles
of the arms and legs.

Xanthomatous involvement of the tongue, how-
ever, is more unusual. I can find only four cases
, mentioned in the literature. Spencer and Cade^
report a female, aged forty-five, who presented
herself at Westminister Hospital in 1926 with a
small tumor on the right border of her tongue.

Fig. 1. Postoperative microsection showing the tumor.

She had been treated for diabetes. The tumor
was excised without incident. They had a simi-
lar case in 1922. Butlin^ had a patient who was
jaundiced and had numerous xanthomata with
two pea-sized nodules on the tongue which on
excision were typical xanthoma. Smith, ^ in 1912,
reported a case similar to Butlin’s.

A sixty-year-old, white, Finnish man presented him-
self at the University Hospital clinic on August 10,
1938. He complained of a lump on the left border of
his tongue of three years’ duration which had grad-
ually enlarged. The lesion was moderately painful and
tender.

Examination was essentially negative save for the
tongue which was altered by the presence of a tumor
4 X cm. on its surface. It was oval, white, firm,
slightly raised and tender. There was no history or
evidence of diabetes. No other lesions were foimd.
Pathological diagnosis was xanthoma. The tumor was
excised under avertin anesthesia on August 14, 1937.
It was well encapsulated, shelling out easily. Post-
operatively the tongue healed without complication and
on August 26 the patient was discharged.

Two months following the excision there was no
evidence of recurrence of the tumor.

The microphotograph demonstrates the lesion in the
tongue.

19600 Grand River

References

1. Butlin: Diseases of the Tongue.

2. Smith; N. Y. Path. Soc., 1920-22, page 139.

3. Spencer and Cade: Diseases of the Tongue, p. 274. P.

Biakiston’s Son & Co., 1931.

^MSMS

Cerebral Anoxia and
Craniocerebral Injnries*

By Frederic Schreiber, M.D.

Detroit, Michigan

Frederic Schreiber, M.D.

M.D., Harvard Medical School, 1923. Pro-
fessor Neurological Surgery, Wayne Univer-
sity College of Medicine. Extramural Lec-
turer in Postgraduate Medicine, University of
Michigan. Member, The American Board of
Surgery, The American Board of Neurological
Surgery, Central Surgical Association, Harvey
Cushing Society, Michigan State Medical So-
ciety.

“ The neurological surgeon is constantly engaged
in mortal combat with the five-headed hydra
of cerebral anoxia. These five heads are; (1)
anoxic anoxia, in which the arterial blood is in-
sufficiently saturated with oxygen; (2) anemic
anoxia, in which the oxygen capacity of the
blood is abnormally low ; ( 3 ) stagnant anoxia,
in which the blood circulation is too slow; (4)
histotoxic anoxia, in which the utilization of oxy-
gen by the cell is hindered by extrinsic agents;
and (5) neurohumeral anoxia, in which cerebral
oxidation is hindered by a disarrangement of es-
sential cell components. Depending on the extent
of the assault, these heads may singly, or in
combination, destroy neuronal tissue. Consider-
able cerebral tissue may be permanently lost as
a result of anoxic insult and yet the life of the
individual may be spared. The object of treat-

*Read before Michigan State Medical Society, the 7Sth an-
nual meeting, Detroit, Michigan, September 26, 1940.

August, 1941

603

CEREBRAL ANOXIA— SCHREIBER

ment in most cerebral conditions is not only to
save the patient’s life, but also, which is often
more important, to safeguard the cortex as much
as possible from the ravages of cerebral anoxia.
It should be obvious that any method of treat-
ment which increases the anoxic hazards of the
brain cell also increases the mortality and mor-
bidity in these cases and cannot, therefore, prop-
erly be called a method of treatment.

Anoxic Anoxia

A consideration of craniocerebral injuries and
the manifestations and mechanisms of cerebral
anoxia will outline some principles which have
application in all forms of neurological surgery.
The mortality and morbidity are extremely high
in those cases of craniocerebral injury in which
there is evidence of respiratory difficulty, and a
much better prognosis can be given if no concom-
itant respiratory difficulty exists. When the res-
piratory center in the medulla is thrown out of
rhythm as a result of trauma, the brain is de-
prived of its oxygen supply from the lungs, with
resulting anoxic anoxia. Inhalations of high
oxygen concentrations may offset this critical
state if the respiratory rhythm can be reestab-
lished fairly quickly before lethal damage results.
Unfortunately, however, stimulants or oxygen
administered in some cases of severe medullary
trauma have the same effect as whipping a dead
horse, and the cerebral cells die before oxygen
can be supplied to them in adequate amounts.

The anoxic anoxia caused by mucus or by
the tongue obstructing air passages of the
unconscious patient following head injury can,
of course, be remedied by an airway, turning
the head on the side, or aspirating the mucus.

If the weather is very warm, or if the un-
conscious patient has fever, which is usually
present if the function of the brain stem has been
interfered with by trauma or destroyed by
anoxia, then an extra ration of oxygen must be
supplied by mask or tent. The oxygen demand
is increased by external heat or fever to a degree
beyond the ability of the vital mechanisms to
supply it in adequate amounts, with a resulting
relative anoxic anoxia.

Stagnant Anoxia

Stagnant anoxia is present in very many cases
of serious brain injury. The cerebral circulation

is slowed as a result of intra- or extracerebral
hemorrhage, or because of perineural or perivas-
cular edema associated with anoxia, thus setting
up a vicious circle. The patient may be irritable,
restless, maniacal, convulsive or stuporous, de-
pending on the degree of oxygen want and the
brain areas involved. There is often the tempta-
tion to restrain these patients with drugs when
they disturb relatives, nurses or other patients.

However, when morphine, barbiturates or
other sedatives are given in dosage sufficient
to quiet this patient, it must be remembered
that histotoxic anoxia produced by these drugs
is added to the already present stagnant anoxia
and the combined effect of these two anoxic
factors only makes the situation of the oxy-
gen-hungry cerebral cells more desperate.

The fact that such a patient is quieted by seda-
tive drugs does not mean that his condition has
improved : indeed, his chances for recovery may
have been definitely lessened. The undesirable
effect of giving narcotics to the restless patient
following head injury has been recognized and
warned against for many years by all neurologi-
cal surgeons. To further deprive the cerebral cor-
tex of oxygen when the clinical evidence of oxy-
gen want is already present is like kicking a
drowning man in the face when he comes up for
air. Usually if the patient who is suffering from
stagnant anoxia associated with head injury is
not restrained, but is allowed to turn about on
a wide mattress or on two beds lashed together,
he will quiet down and come to his senses. If
restraint is necessary, physical restraint is much
safer for the life and cortex of the patient than
restraint with drugs.

Anemic Anoxia

If considerable blood has been lost by an indi-
vidual with a craniocerebral injury, any mental
confusion and restlessness may be in part due
to anemic anoxia. Every effort should be made
to make it easier for the remaining red cells to
support life by carrying oxygen, and therefore
a supply of high concentration of oxygen by
tent or mask, and transfusion should be afforded
as quickly as possible. I have seen extensive cor-
tical disintegration as a result of an hour of
anemic anoxia from hemorrhage coincident with
the stagnant anoxia of low blood pressure result-

604

Jour. M.S.M.S.

CEREBRAL ANOXIA— SCHREIBER

ing from considerable blood loss. The brain
damage may be permanent, depending on the
degree of anoxia, even if adequate blood volume
and circulation are reestablished. Here again,
narcotic and sedative drugs are not only ill-
advised but much less efficient in controlling
restlessness and mania than are pure oxygen
inhalations and blood transfusions.

The use of pleonectic drugs such as sulfanila-
mide must be considered under the head of
anemic anoxia and their anoxic effect properly
evaluated in the treatment of craniocerebral in-
juries. A full dose of sulfanilamide may re-
duce the capacity of one-third of the red blood
cells from carrying the normally required amount
of oxygen, thus producing the same effect in the
patient had he lost a third of his red blood cells
from hemorrhage. Normally the brain can tol-
erate the oxygen deprivation of sulfanilamide
with relative safety, and the occasional neuro-
logical manifestations are due to temporary cell
dysfunction rather than the result of irreversible
cell change.

However, the widespread prophylactic use
of sulfanilamide in craniocerebral injuries to
lessen or prevent infection, is attended with
risk of consequential importance. Frequently
the cerebrum, which has already had some
anoxic insult as a result of injury, cannot tol-
erate the added burden incident to the admin-
istration of sulfanilamide.

Anesthetics

When surgery is necessary in craniocerebral
injuries, as in the case of depressed fractures,
extradural hemorrhage, subdural hematomas or
hydromas, the choice of an anesthetic is vitally
important. The patience required in operating
on these cases under local anesthesia rather than
general anesthesia is rewarded by decreased mor-
tality and morbidity. The added histotoxic anox-
ia from a general anesthetic, no matter how
expertly given, may tip the scales against re-
covery in an individual whose brain is struggling
against the stagnant anoxia resulting from in-
creased intracranial pressure. The neurological
surgeon has learned of the untoward effects of
narcotics and general anesthetics, in cases with
increased intracranial pressure through tragic ex-
perience.

The obstetrician is faced with a similar situa-

tion in his practice. Histotoxic anoxia in the
fetal brain is caused by drugs and anesthetics,
before stagnant anoxia is superimposed by in-
creased intracranial pressure in the birth canal.
It is immaterial whether one type of anoxia pre-
cedes the other. The danger to the cerebral cells
results from the combined anoxic effect, which,
if severe enough, can permanently destroy brain
tissue.

Neurohumeral Anoxia

Neurohumeral anoxia must be guarded
against in the unconscious patient who has
suffered a craniocerebral injury and who may
not have had sufficient fluids or food for sPme
time. If the available salts or sugars in the
cerebral cells become depleted, cellular oxida-
tion cannot take place and typical anoxic de-
generative lesions may occur. The alcoholic
patient who has had a severe head injury fre-
quently presents this problem. He may not
have taken food for some days and often
enters the hospital in a dehydrated condition
with an extremely low blood sugar. He may
be maniacal, unconscious or having convul-
sions. Morphine or other sedatives should
never be given to this type of patient. A
nasal tube should be passed and orange juice,
milk and eggs introduced into the stomach.
One advantage of the tube feeding over the
intravenous injection of sugar or salt solu-
tions is that the stomach can select the neces-
sary food and fluids better than the surgeon
can estimate the right amount of sugar, salt
or fluids to be placed into a vein; also less
damage is done by the wild patient who pulls
out his nasal tube than the one who dislodges
his intravenous needle. If intravenous fluids
are given, care must be taken not to give
more fluids than the brain cells can tolerate.
Anoxic cerebral lesions as a result of intra-
venous feeding in too large volume can be
demonstrated at autopsy.

I would like to report a case which illustrates some
of the points in this discussion. During the hottest
week of summer I was called to see a young man,
a fairly heavy user of alcohol, who had received
a fracture through a frontal sinus as a result of an
automobile accident. He had walked into the hospital
complaining of some headache and was put to bed.
Fluid intake was limited to 1000 c.c. daily. Because
of the sinus fracture he was given heavy doses of
sulfanilamide. He became irritable and was given nar-

August, 1941

605

PNEUMONIA— JENNINGS

cotics and barbiturates in fairly large amounts. On
the third day after admission he developed a tempera-
ture which remained at 105° for three days until the
time that I saw him in consultation. On examination
there was no evidence of meningeal infection. The
patient was cyanotic, drowsy and very irritable. His
pulse and respirations were rapid. Deep reflexes were
all exaggerated.

The patient was given as much water and orange
juice as he would drink, sulfanilamide was discontinued
and he was placed in a cool oxygen tent with a ten
liter flow. His temperature came down immediately,
his irritability and drowsiness disappeared and he has
remained entirely well since this time.

This man gave a clinical picture of cerebral anoxia.
The anoxic factors to be considered were: (1) anoxic
anoxia (extremely hot weather with increased oxygen
demand) ; (2) anemic anoxia (oxygen carriers tied up
by sulfanilamide) ; (3) stagnant anoxia (trauma with
increased intracranial pressure) ; (4) histotoxic anoxia
(alcohol, morphine, barbiturates) ; (5) neurohumeral
anoxia (dehydration). No one, of course, can say
which of these factors were responsible for this pa-
tient’s alarming symptoms of cerebral anoxia. How-
ever, he responded to a “shotgun” reduction of the
possible anoxic factors in his case.

The clinical manifestations of cerebral anox-
ia have a regular pattern and sequence re-
gardless of the anoxic mechanisms involved.
However, the individual effects of various an-
oxic mechanisms, present in any one case of
craniocerebral injury, are difficult to evaluate,
since there are no exact laboratory guides.
Every method of therapy in craniocerebral
injuries must have as its motive a reduction
in the summation of anoxic effects with a con-
sequent decrease in the mortality and morbid-
ity of these cases.

10 Peterboro Street

MSMS-

POSTGRADUATE PROGRAM

Complete schedule of the Michigan Post-
graduate Program will be pub-
lished in the September
Journal.

MSMS-

60t*

Pneumonia

Clinical Diagnosis*

By Alpheus F. Jennings, M.D.

Detroit, Michigan

Alpheus F. Jennings, M.D.

A.B., University of Michigan, 1907. M.D.,

Harvard University, 1910. Attending Phy-
sician, Director of Medicine and Chairman
of the Medical Board of the Charles Godwin
Jennings Ho^ital. Fellow of the American
College of Physicians. Diplomate of the
American Board of Internal Medicine. Mem-
ber, Michigan State Medical Society.

" Not many years past, the early diagnosis of
pneumonia was an erudite achievement afford-
ing renown to the physician but little benefit to
the patient. Now this is different. There are at
present two specific methods of treatment but to
be successful they must be administered in the
early days of the disease. Of otherwise healthy
persons diagnosed and treated on the first day,
all but the exceptional case will recover. The
chance of recovery decreases with each day that
the disease goes unrecognized and after the
fourth day specific treatment adds little to the
patient’s natural ability to recover. The diag-
nosis should be made preferably within forty-
eight hours of the onset.

If the onset is abrupt the symptoms are chills,
followed by fever, pain in the chest, cough with
rusty sputum and dyspnea. In such case the
are those of a rather severe common cold and
diagnosis is obvious. More often the symptoms
frequently the pneumonia follows a common
cold in such manner that is it difficult to state
at what time it began.

The symptoms of the first few days are
deceptive in their mildness but the physician
may be on the watch for several features. One
is, that while the patient insists that he has
only a little cold, he is, nevertheless, unduly
sick and prostrated and takes readily to bed.
The other is, that an initial exhilaration may
make the patient noticeably alert and un-
conscious of his illness.

Even during this period the blood culture
may be positive. After two to four days of
these symptoms the unmistakable clinical pic-

*Read as part of a symposium on pneumonia before the
Wayne County Medical Society, January 20, 1941.

Jour. M.S.M.S.

PNEUMONIA— JENNINGS

ture of severe pneumonia becomes apparent, but
in the meanwhile the most valuable time for
treatment will have been lost, if the physician
is not awake to the possibility of it.

Physical Signs

As it is with symptoms so it is that physical
signs are usually deceptive during the first few
days. Consolidation is rarely detected. The early
signs are suppression of respiration over one
lobe, an area of rales or an area of faint bron-
chial intonation of the spoken voice or whisper,
without bronchial breathing. Dullness is us-
ually absent. There is no standard method of
eliciting rales. In one case they are heard after
cough, in another on sharp respiration and in
still another on normal breathing. Pleural fric-
tion may be heard. The temperature is usually
above 102.5°, which, in an adult, is seldom the
case in a simple respiratory infection. The pulse
is not rapid in the case of moderate severity.
If it is, it indicates a fatal outcome except for
specific therapy. An especially valuable early
sign is elevation of the respiratory rate and this
may not be obvious unless the physician sits
quietly by the bedside and counts it with his
watch. The physical examination must be
thorough and made with care and deliberation.
No consideration of inconvenience to the patient
or demands upn the physician’s time should be
permitted to interfere with it.

I have purposely omitted from this discussion
consideration of the diagnosis of the fully de-
veloped case of pneumonia since there is noth-
ing I can add to your knowledge of it. The
features that I have mentioned serve to raise a
strong suspicion of pneumonia rather than to
conclusively diagnose it. When the suspicion
has been entertained it must be confirmed by
laboratory studies.

Laboratory Examinations

The study of th6 sputum is indispensable
in the diagnosis of pneumonia. It entails
little effort on the part of the physician. He
merely obtains a suitable receptacle in which
the specimen will not quickly lose its mois-
ture, he encourages the patient to cooperate
and he then delivers the specimen to the lab-
oratory. Hospitals should make the facilities
of their laboratories available to members of
their staffs for this purpose. If the sputum

is to be kept some hours before delivery to
the laboratory it should be placed in the
ice box to prevent overgrowth by nonpatho-
genic organisms.

If, in the presence of symptoms mentioned
previously, pneumococci are found in the spu-
tum, the diagnosis of pneumonia may be con-
sidered established. It is true, as Dr. Frisch
will, I hope, show, that certain types of pneumo-
cocci are found in the sputum of uninfected per-
sons and also that certain types are relatively
avirulent. Nevertheless, when a matter of diag-
nosis is under consideration no type should be
ignored. Pneumococci are found in the sputum
of from 80 to 96 per cent of all cases of pneu-
monia. The percentage found in any series will
depend upon the nature of the prevailing epi-
demic, the care with which the sputum is ob-
tained and the accuracy of the laboratory. Be-
sides confirming the diagnosis, the presence of
pneumococci in the sputum indicates that chem-
otherapy or serotherapy should be instituted at
once and it is the only means except blood cul-
ture to determine which type serum should be
used.

Second to the pneumococcus the streptococcus
is most commonly found in the sputum. Mor-
phologically it may resemble the pneiimococcus
but it differs in that it fails to react to the
Neufeld test. Its presence suggests chemo-
therapy, but the results may be disappointing.
Pneumonia due to the staphylococcus has been
in the past rapidly fatal. Both chemotherapy
and serotherapy are now of value when the
organism is present. The Friedlander bacillus
is the cause of about 1 per cent, of pneumonias.^
It is not related to the pneumococcus, being a
member of the Tribe Escherichise. Neverthe-
less, some hope has appeared that both chemo-
therapy and serotherapy may be effective against
it.^ The role of the influenza bacillus is still to
be decided and no treatment has been demon-
strated as yet.

When none of these organisms is found
and the sputum contains only the common
mouth bacteria, information of value still has
been provided. In this case one may con-
clude that there is either a virus pneumonia
or that some disease other than pneumonia
is present. The only result to be expected

August, 1941

607

PNEUMONIA— JENNINGS

from chemotherapy is intoxication of the pa-
tient and there is no reason to use serum.
In rare instances tubercle bacilli are found in
the sputum and the case proves to be one of
acute tubercular infection.

The blood culture can be made at the bedside.
We have rubber capped flasks which can be car-
ried without chance of contamination. The
inoculation is made by plunging the needle of the
syringe through the cap immediately after with-
drawal of the blood. Blood culture should be
made when the decision to start intensive treat-
ment has been reached, since the blood may be-
come sterile thereafter. The blood culture, if
positive, affords two items of information. The
first is that the bacterial etiology is established
and the second is that the case is proved to be
one of desperate outlook unless it can be con-
trolled by treatment. At times the blood culture
is positive when the symptoms appear incon-
sequential.

The x-ray will reveal consolidation when it
cannot be detected by physical signs and
theoretically it is advisable in every suspected
case. It will not distinguish the infecting agent
nor will it differentiate pulmonary infarction
from pneumonia. Even when films have been
made the clinician will need to exercise his judg-
ment. There are a certain number of minor
shadows which are found in simple respiratory
infection and which are puzzling to the roent-
genologist. At times the film will fail to reveal
consolidation even though the physical signs of
it are detected, or it would seem certain that it
is present. Its use is limited by its cost and
restricted availability outside of hospitals.

The blood count in pneumonia shows a poly-
morphonuclear leukocytosis. The only exception
to this is those cases in which the blood response
is overwhelmed by the toxemia, and which are
obviously desperately sick. In them the diag-
nosis rapidly becomes evident by the characteris-
tic symptoms and signs.

Differential Diagnosis

Because of their having somewhat similar
symptoms and physical* signs several conditions
need be distinguished from pneumonia. Fortu-
nately, each has one or more sharply differ-
entiating feature. Bronchopneumonia need not

be separated from lobar pneumonia for purposes
of this discussion since treatment is identical in
each.

In acute tubercular pneumonia the tubercle
bacilli are always present in the sputum.

Either serous or purulent pleural effusion may
occur abruptly. There is in them absence of
tactile fremitus, a sign frequently overlooked by
both students and practitioners.

Pulmonary infarction is recognized mainly by
its association with other diseases, namely, arter-
iosclerosis, heart disease, operations, childbirth,
trauma, infections and thrombo-phlebitis which
may often be concealed. The sputum shows the
common mouth bacteria only.

The signs of consolidation may be found in
certain forms of acute rheumatic fever. The
pulse is elevated far out of proportion to the
fever, and pericarditis is present.

A form of pneumonia due to a virus^ has been
recognized in recent years as a consequence of
bacteriological studies. In this disease all the
characteristics of pneumonia are present, but the
sputum shows no predominating organism and
the blood culture is sterile.

It is to be expected that a pandemic of true
influenza may break forth soon. In addition to
respiratory symptoms, there are in the disease
intense headache, backache and pains in the ex-
tremities. In severe forms collapse occurs early.
There is leukopenia and the sputum is negative
unless secondary invading organisms are de-
tected.

Conclusion

The temptation is great to administer one of
the chemotherapeutic agents at the onset of any
respiratory infection, and thereby avoid the
laborious diagnostic studies which have been
enumerated. There are several embarrassing
results of such a course. In the first place,
chemotherapy cannot as yet be depended upon
as the sole cure for pneumonia. In the second
place, accurate diagnosis is rendered difficult be-
cause, as Frisch® has shown, chemotherapy di-
minishes the numbers of pneumococci in the
sputum and may thus interfere with accuracy of
typing. The patient may thereby be deprived of
serum therapy that he should have. Thirdly,
if the patient fails to respond to this treatment
within a few days there will then ensue a state
of utter confusion with the physician uncertain

Jour. M.S.M.S.

608

EUNUCHISM— MILLER

whether the symptoms are caused by drug or by
disease and, if disease, which disease. And
finally, serious toxic effects of the drug are
bound to occur at best, and my own impression
is that these toxic effects are more common when
the drug is given in the absence of organisms
susceptible to its action.

The conclusion is obvious. Spare no effort to
reach a working diagnosis if possible before
therapy is instituted. If chemotherapy appears
imperative before the diagnosis is established, do
not relax but rather intensify the diagnostic
studies.

Bibliography

1. Bullowa, J. G. M. : The Management of the Pneumonias.

New York: Oxford University Press, 1937.

2. EditoriaL Jour. A.M.A., 115:2180, (December 21) 1940.

3. Frisch, A. W. : Sputum studies in pnetraonia. The ef-

fect of siilfanilamide. Jour. Lab. and Clin. Med., 25:361,
(January) 1940. , „ „

4. Lord F. T., Robinson, E. S., and Heffron, R. : Clmmo-

therapy and Serum Therapy of Pneumonia. The Com-
monwealth Fund, 1940.

-MSMS-

Eunuchism

Treatment with Testosterone
Propionate

(Report of a Case)

By Hazen L. Miller, M.D.

Detroit, Michigan

Hazen L. Miller, M.D.

M.D., University of Michigan, 1920. Mem-
ber of Attending Staff of the Division of
Urology, Highland Park General Hospital,

Courtesy Member of Division of Urology,

Mount Carmel Mercy Hospital. Member of
Wayne County Medical Society. Member of
Michigan State Medical Society.

■ The positive and striking effect of testos-
terone in patients lacking testicular sub-
stance is now a conceded phenomenon. That
it is also the only effective method of bring-
ing about puberty or reestablishing a sex life
in males, who, because of anomaly or injury,
have not sufficient testicular tissue, is an es-
tablished endocrinological fact.’'’®’®’“

However, there are many phases of this
hormone’s activity which are not clear. The
effect on the development of the prostate and
its hypertrophy is one of them.^’^ The hyper-
trophy of the kidney which Selye found to
occur in experimental animals also invites
study.® The masculinizing effect of testoster-

one propionate on the female^’®’® should es-
pecially be kept in mind in considering the
case here reported.

These considerations and the relative rarity

Fig. 1. (Left) General appearance when first seen. (Right)
General appearance four months after implantation of pellets
of testosterone propionate.

of such conditions prompted the writer to re-
port this case.

The patient, apparently a male and nine-
teen years old, came to the Out Patient De-
partment on August 1, 1939, because of fail-
ure of sexual development and blindness of
the left eye. The blindness was due to an
injury seven years previously. He had never
experienced sexual desire, erections or ejacu-
lations.

About five year before, an operation for
cryptorchidism was performed at Toronto Gen-
eral Hospital. The condition found is de-
scribed in the following report :

“This unfortunate boy of fifteen came to the hos-
pital for investigation and treatment of cryptorchidism.
Examination showed the penis to be infantile in type —
the scrotum to be small and empty ; there was no
growth of pubic hair, or in fact anywhere else on
the body. A careful palpation in the region of the
internal ring and inside was suggestive of a small mass
which was taken to be the testis. Exploration was
carried out and on both sides a similar finding was

6p9

August, 1941

EUNUCHISM— MILLER

encountered. At the internal ring was an oval mass
about the size of an almond which felt like a testis,
but on being visualized looked like a lymph gland.
Quick section was done and it was reported lymph
gland. Careful examination revealed no sign of a

Fig. 2. (Left) Genitalia when first seen. (Right) Genitalia
four months after implantation of pellets of testosterone pro-
pionate.

testis. Palpation in the extraperitoneal pelvis gave
no sign of a uterus or ovary. The wounds were
closed; the conjoined tendon being sutured to Pou-
part’s. Pre-operative examination revealed no sign of
an ectopic testis. Pathological report on the tissue
was ‘chronic lymphadenitis.’ ”

This individual had the appearance of a girl
dressed in boy’s clothes. He was 5 feet, 9^
inches in height and weighed 122 pounds.
His manner was languid and he seemed
to lack energy. His formal education was
carried only through the third grade because
of his father’s peripatetic occupation, but he
seemed quite well informed for his age and
answered questions promptly and intelligently.
He evinced an interest in girls but has never
attempted any sexual approach, giving as his
reason, ‘T would look foolish attempting any-
thing with what I have.” He has tried mas-
turbating with a resultant slight engorgement
of the penis producing about a 1 cm. increase
in length. He appears to be interested in
boyish pursuits, plays football and makes
model airplanes.

The father and mother and two younger
brothers are living and well and apparently
normal.

On physical examination this patient was
of the slender stature above described with a
sexless configuration of the body, tending to
the female type as shown in Figure lA. The
shoulders were small and the musculature was
poor. There was no suggestion of mammary
gland, and no other indication of ovarian
function.

There was a scar on the left cornea. On
the face there was little or no hair and no
axillary or pubic hair. The voice was soprano
in pitch.

There were bilateral inguinal scars. Noth-
ing suggestive of a testicle was palpable either
there or in the scrotum, except for an indefi-
nite thickening at the right external ring.
The scrotal sac was undeveloped and the penis
infantile, measuring about 3 cm. in length and
1 cm. in thickness with a very marked nar-
rowing of the meatus. Rectal examination
revealed no evidence of a prostate gland; no
secretion could be expressed from the urethra.

The extremities were negative except for
extraordinarily long and prehensile fingers and
toes.

Laboratory Findings

Urine : Straw color, alkaline. Albumin, neg^ative.

Sugar, negative. Sediment, occasional WBC. Blood:
Hgl. 90 per cent, RBC 4,640,000, WBC 7,200, filament
60 per cent, non-filament 8 per cent, lymphocytes 30
per cent, endocytes 2 per cent. Blood N.P.N. 29 mg.
per 100 c.c. blood. Blood sugar 115 mg. per 100 c.c.
blood. Blood Kahn negative. An Ascheim Zondek
test was not done.

Blood pressure was 120 systolic and 60 diastolic.

On October 5 a meatotomy was done increasing
the caliber of the meatus from 18 F to 24 F. How-
ever pyelographic studies of the upper urinary tract
were carried out by the excretory method on October
28 because of the yet infantile penis. These pyelograms
(Fig. 2A) show actively secreting kidneys, but are
rather small for the patient’s age and size.

Treatment

This patient was first treated with Antuitrin
S throughout the month of August, 1939, re-
ceiving 500 rat units intramuscularly every
two or three days to a total of 7,000 rat units.
There was no apparent change in his condi-
tion.

He was then given testosterone propionate,
25 mg. intramuscularly, receiving five injec-
tions the first week and two injections a week

610

Jour. M.S.M.S.

EUNUCHISM— MILLER

after that for five months. He received a
total of forty-six injections of 25 mg, each,
thus consuming 1,150 mg. of this expensive
preparation in less than half a year.

with discharge of a starchy substance re-
sembling semen until the seventh week.

Within a week of the beginning of his re-
placement therapy he felt “more peppy,”

Fig. 3. (Left) Excretory pyelogram before testosterone propionate therapy. (Right)
Excretory pyelogram one year after commencing testosterone therapy.

The effects were instantaneous, sustained
and gratifying. The penis, during the first
week, became somewhat sore without any
pleasurable sensation and there was consider-
able edema of the prepuce and scrotum. How-
ever, this soreness and edema disappeared in
a week and the penis proceeded to increase in
size in its flaccid state from the original length
of 3 cm. to 4 cm. at the fourth week, 5 cm.
at the sixth week and at the conclusion of his
injections had attained the nearly normal size
of 7 cm. All measurements were made from
the symphysis to the tip of the glans. At
first there was almost constant penile engorge-
ment and erections occurred several times
daily, lasting about a quarter of an hour. Dur-
ing this acute response a small amount of
blood was once noted coming from the ureth-
ra.

Approximately one month after the begin-
ning of his injections of testosterone propio-
nate, the patient observed that he had experi-
enced “sexual desire since taking the shots ;
before it never bothered me.” Also about this
time he reported that a viscous substance
came from the urethra following defecation;
but he did not have a nocturnal emission

August, 1941

whereas he had felt “grogg^^” before. This in-
crease in energy was soon accompanied by a
visible increase in musculature. In one month
the patient gained from 122 pounds to 137
pounds. In two weeks more he weighed 142l4
pounds and at present weighs 149 pounds.
This immediate gain is interesting in view of
the work of Thorn and Emerson on the pro-
duction of edema by gonadal and adrenal cor-
tical hormones.^® During the past year the
patient has increased in height from 5 feet,
9^4 inches to 6 feet.

A growth of pubic hair became noticeable
in three weeks and soon afterward a beard
and axillary hair. It was nearly two months,
however, before this hair growth became as
prominent as that of a boy at the beginning
of puberty. At about this time his voice be-
gan to become deeper and “crack” occasion-
ally.

Early in his treatment the patient observed
that his breasts were “developing.” On exam-
ination there was found to be a slight swelling,
induration and tenderness in the right nipple
region, and later the same on the left. Noth-
ing further was ever evident and at present
there is nothing resembling a female breast.

611

UTERINE INERTIA— SIDDALL

As stated previously, at the end of five
months the supply of testosterone propionate
was exhausted and the patient’s treatment
lapsed, but without any apparent regression
on his part during a three-month period.
Through the courtesy of the Schering Corpora-
tion, pellets suitable for implantation were
then obtained, and implanted in the left axil-
lary region by Dr. C. J. Barone, an associate.
Two pellets of 150 mg. each were used.

There was an immediate renaissance in sex-
ual activity. Prolonged erections occurred
about five times daily, and frequent emissions
were noted for some time. He reports now,
eight months after implantation, that these
emissions do not occur and the erections are
diminishing. The voice continues to deepen
and the pubic and axillary hair to thicken.
There is fairly well developed facial hair, but
no hair on the chest. The penis is quite well
developed ; flaccid, it measures 7 cm. in length
and 3 cm. in diameter; when erect, the length
is 12 cm. and the diameter between 4 and
5 cm. The denser tissue suggesting a small,
rather amorphous testicle palpable at the
right external ring, is still present and per-
haps slightly larger. A small, firm prostate
is palpqble by rectum and is not tender. No
secretion could be expressed from this on re-
peated attempts. However, the secretion dis-
charged from the meatus upon manually in-
duced ejaculation, has the gross appearance
of , prostatic fluid, not semen, and microscopic-
ally shows a moderate concentration of lipoid
globules and no spermatozoa.

Excretory pyelograms were made on Octo-
ber 28, 1939, at the beginning of his treatment
and again in December, 1940. These proposed
to show clinically the hypertrophic influence
of testosterone propionate on the kidney as
demonstrated by Selye^ experimentally. As
will be noted (Fig. 2A-B), there is no very
marked change in the size of the kidney in
this patient after rather prolonged therapeutic
dosage.

References

1. Burch, John C. : Endocrine therapy in obstetrics and gyne-

cology. Surg., Gynec. and Obst., 70:503-S0'8.

2. Geist, Samuel H.. Salmon, Udall J., Gaines, J. A., and

Walter, R. I. : The biologic effect of androgen (testos-
terone propionate) in women. Jour. A.M.A., 114:1539-

1544, 1940.

3. Huggins, Charles, and Stevens, Roland A.: The effect

of castration on benign hypertrophy of the prostate in
man. Jour. Urol., 4^705-713, (May) 1940.

4. McCahey, James F., and Rakoff, A. E. : An estrogenic

612

property of testosterone propionate. Jour. Urol., 42:372-
375, (September) 1939.

5. McCullagh, E. Perry: Treatment of testicular deficiency

with testosterone propionate. Jour. A.M.A., 112:1037-1044.

6. McCullagh, E. Perry, and McGurl, F. J. : Further ob-

servations on the clinical use of testosterone propionate.
Jour. Urol., 42:1265-1273, (December) 1939.

7. Selye, Hans: The effect of testosterone propionate on the

kidney. Jour. Urol., 42:637-641, (October) 1939.

8. Thompson, Willard 0. : Male hypogenitalism. Jour. Michi-

gan State Med. So., 39:842-847, (November) 1940.

9. Thomson, David S. : Relations between enaocrinology and
urology. Jour. Urol., 41:435-454, (April) 1939.

10. Thorn, George W., and Emerson, Jr., Kendall: Role of

gonadal and adrenal cortical hormones in the production
of edema. Ann. Int. Med., 14:757-769.

11. Vigdoff, Ben: The hormonal control of the prostate and

its relation to clinical prostatic hypertrophy. Jour. Urol..
42:359-367, (September) 1939. ^ ^ J

-MSMS-

Uterine Inertia in the First
Stage nf Labnr*

By Roger S. Siddall, M.D.
Detroit, Michigan

Roger S. Siddall, M.D.

M.D., Johns Hopkins University, 1920. Cer-
tified by the American Board of Obstetrics
and Gynecology. Assistant Professor of Clin-
ical Obstetrics and Gynecology, Wayne Uni-
versity. Extramural Lecturer in Post-Gradu-
ate Medicine, University of Michigan. On
the staffs of Harper Hospital, Highland Park
General Hospital, and Herman Kiefer Hospi-
tal, Detroit. Member, Michigan State Medi-
cal Society; Michigan Society of Obstetricians
and Gynecologists.

■ Of all the causes of dystocia or difficult
labor, uterine inertia, with its weak and in-
sufficient contractions, is perhaps the most
frequent and troublesome. As little is known
about its etiology, the condition is so unpre-
dictable as to make prevention impossible for
the most part. For the same reason, there is
as yet no direct and certain remedy. Treat-
ment must therefore depend largely on a
careful consideration of possible complications
and dangers, and their best management.
Here, as in other conditions, knowledge ac-
cumulates and opinions change with experi-
ence, and so another review of an old sub-
ject may be justifiable.

As an example of a more or less personal
opinion, it would seem to me that the prob-
lem of uterine inertia particularly concerns
the first stage of labor, since it is generally
agreed that persistent delay in progress after
full dilatation of the cervix offers a clear-cut
indication for feasible delivery by mid or low

*From Herman Kiefer Hospital and the Division of Obstetrics
and Gynecology, Wayne University. Presented before the
Kalamazoo Academy of Medicine, March 18, 1941.

Jour. M.S.M.S.

UTERINE INERTIA— SIDDALL

forceps, or extraction in breech presentations.
Again, the customary division of inertia into
primary and secondary appears to have little
practical importance as the problems to be
solved are essentially the same in either event.
Consequently, this discussion will apply almost
exclusively to uterine inertia in the first stage
of labor, and without regard to its time of
onset. Also, only incidental mention will be
made of other causes of prolonged labor,
though it is recognized that they often play
a part along with inertia.

Incidence

The incidence of uterine inertia varies some-
what with the types of patients. Those in
their first labors are more likely to be affected
than are multiparas, although the latter are
certainly not exempt from the trouble. In
some reports, occurrence is given as high as
10 per cent, but in the general run of obstet-
rical patients it probably is actually hardly
one-half that figure — especially if the custom-
ary arbitraiy^ duration of thirty hours or
over is accepted as the criterion of prolonged
labor. Moreover, care must be taken not to
include cases with vague pains but not defi-
nitely in labor. With all proper statistical
safeguards, the incidence is yet of considerable
practical significance for the obstetrician.

Etiology

The etiology of this condition is most ob-
scure— as should be expected when it is re-
membered that we have little more than spec-
ulative evidence regarding the cause of onset
and continuation of labor pains. As noted
before, women in their first labors are more
subject to the trouble, and this is said to be
especially true with elderly primiparas. Cer-
tain other predisposing conditions are often
mentioned, such as mild bicornuate or arcu-
ate uterus ; overdistention from multiple preg-
nancy, hydramnios, or large child ; uterine
fibroids ; pelvic adhesions ; and unusual fear or
other emotional upsets. These factors are so
far from constant in their action, however, as
to offer little help in predicting inertia. Ad-
vanced disease, general debility, and such are
unimportant. In fact, women in poor condi-
tion from tuberculosis, cardiac disease, and
acute infections, for example, tend to have

August, 1941

rather easy labors. Premature rupture of the
membranes is now generally believed to be
more often a result than a cause. Contracted
pelvis and some abnormal presentations have,
unfortunately, a high incidence of complicat-
ing inertia, but from recent studies at Herman
Kiefer and Harper Hospitals we doubt that a
like impression regarding breech’’ and posterior
occiput^ presentations can be verified. Con-
siderable attention to body build has yielded
only generalizations of no great practical
value. The etiology, then, of this important
obstetrical condition is essentially unknown.
Furthermore, there are so many exceptions to
any rules so far laid down that the presence
or absence of any probable or suspected causal
factors gives little certainty regarding the pos-
sible appearance or non-appearance of uterine
inertia in any given case.

Complications and Their Treatment

Where the cause of a condition is largely
guesswork, prevention is likely to be of the
same order. Theoretically, the endocrines
might have some bearing on the problem, but
results with the use of all, even ovarian fol-
licular hormone, which seemed most promising
of any, have been equivocal and unconvinc-
ing. Of some interest, however, has been the
recent report by Wadlo-w^^ and a similar one
by Pomerance and Daichman.® Both of these
small series of women, kept on a diet greatly
restricted in salt, showed averages for the du-
ration of labor appreciably shorter than those
usually accepted. The regime should be harm-
less, though probably hard to maintain, and
no doubt further reports will soon appear by
which we may judge the efficacy of the treat-
ment. As indicated before, efforts in the pre-
natal period directed towards improving the
general health may be futile in the prevention
of uterine inertia but would at least give bet-
ter resistance should this, or any other, com-
plication arise.

Infection. — If we grant, then, that uterine
inertia in labor is largely unpreventable, we
should realize the hazards of the complication
and be prepared to combat them as well as
can be done. One definite danger is intra-
partum infection, with the subsequent in-
creased incidence of puerperal infection for

613

UTERINE INERTIA— SIDDALL

the mother, and high fetal mortality. As defi-
nitely shown (by Harris and Brown, ^ and by
Siddall,® among many others), the intrapar-
tum infection rate increases directly with the
duration of labor, and this is especially the
case if the membranes are ruptured. Certain-
ly, this danger emphasizes the need of meticu-
lous aseptic technic and the limitation of vagi-
nal, and even rectal, examinations during labor
and late in pregnancy. Efforts at more posi-
tive treatment, notably by H. W. Mayes,^ in
which not only is the vulval site prepared in
the usual way but also an antiseptic is in-
stilled into the vagina from time to time dur-
ing labor, has given good results in the hands
of some. Others have found it ,of little use,
and DeLee^ reports an actual increase of in-
fection with the method. I believe that this
technic is probably harmless but as yet am
not entirely convinced of its efficacy.

Exhaustion. — The other major danger is
physical exhaustion — sooner or later, if labor
lasts long enough, jeopardizing the mother’s
life undoubtedly, and probably the child’s also.

Again, it may not be amiss tO' point out that
a diagnosis of exhaustion is not to be based
on the statements of the woman but on a ris-
ing pulse rate and other definite signs of begin-
ning collapse. Recognizing that the treatment
of frank exhaustion in labor is far from satis-
factory, we are wise to anticipate and institute
early measures aimed at prevention, or more
exactly, postponement, of the danger.

The procedures for treatment or postpone-
ment of exhaustion fall, for the most part, into
two groups. First is the promotion of rest
and sleep ; and here it is well to remember
that though morphine gives the most perfect
rest, it also is prone to diminish the already
weak contractions. Barbiturates, with per-
haps small amounts of scopolamine, have less
effect on the pains and are often for this rea-
son chosen though there is the risk of induc-
ing excitement rather than sedation in an oc-
casional patient. An additional small dose
of morphine will usually eliminate this ob-
jectionable reaction. There seems to be no
doubt of the appreciably better results to be
obtained in these cases by emphasis on the
use of analgesic drugs rather freely.

614

Also, of great importance in forestalling ex-
haustion in prolonged labor, is the matter of
food and water. Digestion is impaired during
labor, it is true, but small amounts of easily
digestible food at frequent intervals are well
handled and help to keep up strength and
morale. Of even more consequence is atten-
tion to an adequate intake of water. Many pa-
tients in labor require urging to take anything
by mouth, and where there is vomiting and
with the use of analgesia, dehydration may
become a real problem. Pride and Reinber-
ger® have demonstrated a high frequency of
genuine, and sometimes dangerous, acidosis in
long labors. Incidentally, they attributed
some of the acidosis to the production of lac-
tic acid from muscular activity and, further-
more, found that analgesia limited this, and
hence the acidosis, presumably by promoting
rest and quiet. There would seem to be good
reason back of the common custom of giving
glucose solution intravenously (say, 1000 cu-
bic centimeters of a 5 per cent solution every
12 hours) to patients long in labor in order
to assure them a fair water intake as well as
some readily usable food.

Stimulation of Pains. — Inasmuch as this con-
dition is one of weak and insufficient pains, it
is only natural that efforts should be directed
towards correction of the trouble by stimula-
tion of uterine contractions. The lack of any-
thing but speculative knowledge as to the
initiating impulse causing labor pains has been
an insurmountable difficulty in treating the
actual cause. Trial of the ovarian follicular
hormone has been disappointing^^ as noted be-
fore. On the theory that increased pressure
in the uterus stimulates pains, a tight abdom-
inal binder has been recommended, and it
might well have some effect if it were not
generally too uncomfortable for use. Others
encourage a patient to remain upright or
walking so that gravity will bring the present-
ing part against the cervix, but such activity
is of questionable benefit and, if persisted in,
contributes to exhaustion.

Experience has shown that digital stripping
away of the membranes from the low^er uterine
segment, or perhaps the stretching of the
cervix with such manipulation, sometimes pro-
duces better pains. If vaginal exploration is

Jour. M.S.M.S.

UTERINE INERTIA— SIDDALL

already indicated to rule out malposition or
for other reasons, there should be no contra-
indication to a trial of this procedure. Arti-
ficial rupture of the membranes is more often
successful but is wisely reserved for patients
with considerable dilatation of the cervix and
in whom, in case of failure and the consequent
increased danger of infection, operative deliv-
ery could be reasonably practicable. The hy-
drostatic bag introduced through the cervix is
a fairly efficient stimulator and dilator but
carries with it too much danger of infection
and prolapse of the umbilical cord for routine
use.

Direct stimulation of pains by oxytocic sub-
stances has been the subject of much contro-
versy. Castor oil and quinine either in com-
bination or singly, are old and much used
remedies, though admittedly uncertain in their
action. In fact, there are some who question
any degree of efficacy for either drug. More-
over, evidence has been advanced to show
that quinine may cause deafness of the child
or even its death. However, such dangers
can be only very slight at the most, and the
preponderance of clinical opinion regards both
as sufficiently helpful to justify a trial in many
cases. Perhaps some of the confusion has
arisen because the effect is seldom immediate,
but is evidenced after the lapse of 4 to 6
hours. Paradoxical as it may seem, these
drugs, either alone or together, may be given
with morphine, since the stimulating action
of the former comes into play as the sedative
and recuperative effect of the latter wears
off.

Extracts of the posterior pituitary gland
were at first highly recommended for use in
these cases, and they are undoubtedly efficient
stimulators. But, it was soon learned that
such serious accidents as rupture of the uterus
and death of the child might result, and there
came about a general condemnation of the
procedure. Williams^^ says, “ — its administra-
tion is reprehensible during the first stage of
labor.” Titus^° agrees with this, without res-
ervation. On the other hand, Faber and Mus-
sey,^ and a few others, have maintained that
cautious use of the substance may be defensi-

ble where operative termination of labor would
otherwise be necessary. Some of the staff
members of Herman Kiefer and Harper Hos-
pitals have long held that though large doses
of these substances are highly dangerous, this
fact does not necessarily mean that small
quantities should be so harmful as to be to-
tally contra-indicated. At Herman Kiefer an
experimental study® was made, and the re-
sults can be summarized as follows :

The sixty-two cases were at term, with viable babies,
and had been in definite labor for thirty hours or more,
the dystocia being due to uterine inertia as the only
cause. Either pituitary extract or a solution of the
oxytocic fraction (pitocin) was given at intervals of
twenty to thirty minutes, beginning with 1, 2, or 3
minims and increasing a minim a dose to a maxi-
mum of 5 minims. Whenever good stimulation oc-
curred during a course, administration was, of course,
discontinued at that point. ■ In some instances the
course was repeated after a lapse of several hours,
when the first had been without effect. Among the
sixty-two cases there were forty-two with efficient and
lasting stimulation of pains causing satisfactory com-
pletion of the first stage of labor. Essentially the
same results were obtained for primiparas and multi-
paras. In the twenty classed as failures, there also
was apparently some effect in the majority, as only
three required operative intervention before full dila-
tation of the cervix. In these sixty-two very difficult
cases there were only four stillbirths, and of these not
more than one could possibly be ascribed to the use
of pituitary extract. There were no neonatal deaths,
and the fifty-eight babies bom alive showed no evi-
dence of injury. One maternal death occurred follow-
ing operative interference after full dilatation of the
cervix and was in no way due to stimulation of the
uterus. We were convinced, however, that the method
is not free of danger as there was one instance of
tetanic contraction of the uterus after an initial 2
minim dose — fortunately relieved by ether anesthesia
and without detectable injury to mother or child.
Because of this experience, we recommended a, first
dose of not more than one minim to test out the
reactivity of the uterine musculature.

The foregoing is intended in no way as a
recommendation for the indiscriminate em-
ployment of pituitary extract in labor. There
is always some risk with its use, and large
doses are very dangerous. However, in very
difficult cases of uterine inertia with operative
intervention becoming inevitable, it does seem
that a careful trial of pituitary extract should
be considered as the lesser hazard.

August, 1941

615

UTERINE INERTIA— SIDDALL

Operative Intervention

In the event that all treatment has failed
and the woman with an incompletely dilated
cervix begins to show signs of exhaustion and
infection, operative interference becomes im-
perative to forestall a tragedy. Cesarean sec-
tion is usually out of the question because of
the risk of infection. Experience has shown
that even the formerly recommended low cer-
vical or the extraperitoneal technic, though
affording some protection, are yet associated
with too high a mortality after long labor.
An exception may sometimes be made where
future child-bearing is not desirable or may
be sacrificed, and cesarean section can be fol-
lowed by removal of the uterus. This is neces-
sarily a rare situation since the majority of
these women are in their first labors.

When the cervix is half or more dilated,
completion of the dilatation is to be accom-
plished and the child delivered by forceps or
version and extraction, depending on which is
dictated by the circumstances. With less than
5 centimeters dilatation, it is generally wise
to insert a hydrostatic bag for at least a trial
at promoting some progress before attempting
delivery. For operative enlargement of the
cervix, direct incision according to Diihrssen
has largely supplanted so-called manual dila-
tation, which in fact was not dilatation but
rather manual tearing. Cutting is much quick-
er and, moreover, has the distinct advantage
of permitting the placing of the incisions in
the safest directions. Since the operation is
described in every textbook, little need be
said on the technic.

It has been stated, however, and I believe
the statement is true and worth repeating, that
the commonest mistake in connection -with
this operation is its posponement until too late.
Its well known formidableness leads too often
to ill-advised delay; and finally when the at-
tempt is made, the patient is in the last stages
of exhaustion.

Another and frequent error is found in in-
sufficient incisions. Traction on the fetus,
then, is very likely to result in sudden and
dangerous extension well up into the uterus.

Finally, a word may be said in regard to
one more danger, namely, postpartum hemor-

rhage. Uterine inertia is often followed by
uterine atony, and after successful delivery,
the patient’s life may be again jeopardized by
profuse bleeding. Treatment, of course, is
as usual for postpartum hemorrhage, but an-
ticipation should permit more prompt institu-
tion of the necessary measures.

Summary

Uterine inertia is a common cause of dys-
tocia, especially in first labors though multi-
paras are not exempt from the trouble. In
the second stage of labor, operative delivery is
usually feasible ; but prolonged first stage due
to weak pains is apt to be difficult to treat
and may be dangerous for mother and child.
The actual etiology of uterine inertia is un-
known, and moreover the usually accepted
predisposing factors are so variable in their
effect as to be of little value in predicting the
condition for any given case. Consequently,
attempts at prevention are mostly futile,
though the recently suggested salt-poor diet
may prove to be of some help. The chief
dangers associated with the prolonged labor of
uterine inertia are infection and exhaustion,
and treatment for these is outlined. Direct
stimulation of uterine contractions has been
widely condemned as hazardous but at times
may be justifiable in order to avoid greater
risks. Results are given for an experimental
series of these cases treated by careful ad-
ministration of pituitary extract. In some
instances all treatment fails; and with the
approach of danger, operative intervention be-
comes necessary, and this should not be post-
poned until too late. Cesarean section is usu-
ally contra-indicated. If the cervix is less than
half dilated, the dilating effect of a hydrostatic
bag may be tried. But, when 5 centimeters
or more dilatation has been attained, the gen-
eral indication is for ample incision of the cer-
vix and extraction of the child by forceps,
breech extraction, or version and extraction,
as the circumstances dictate. Postpartum
hemorrhage due to uterine atony often fol-
lows uterine inertia.

References

DeLee, J. B. : Principles and Practice of Obstetrics,

Ed. 7, p. 318. Philadelphia & London: W. B. Saunders
& Co., 1938.

Faber, J. E., and Mussey, R. D.: lied. Clin. North

America, 23:1049, 1939.

616

Jour. M.S.M.S.

UTERINE INERTIA— SIDDALL

3.

4.

5.

6.

7.

8.

9.

10.

11.

Harris, J. W., and Brown, J. H. ; Am. Jour. Obstet. &
Gynec., 13:133, 1927.

Mayes, H. W. : Am. Jour. Obstet. and Gynec., 30:80, 1933.

Pomerance, W., and Daichman, I.: Am. Jour. Obstet. &

Gynec., 40:463, 1940.

Pride, W. T., and Reinberger, J. R. : Am. Jour. Obstet.

and Gynec., 35:793, 1938.

Seeley, W. F., and Siddall, R. S. : New Internal. Clin.,

1:29, 1940.

Siddall, R. S.: Am. Jour. Obstet. and Gynec., 15:828,

1928.

Siddall, R. S., and Harrel, D. G.; Am. Jour. Obstet. &
Gynec., 41:589, 1941.

Titus, P.: Management of Obstetric Difficulties, p. 391.

St. Louis: C. V. Mosby Co., 1937.

Wadlow, E. E.: Am. Jour. Obstet. & Gynec., 39:749,

12. Weisman, A. I.: Med. Rec., 153:52, 1941.

13. Williams, J. W. : Obstetrics, ed. 7, p. 924. New York:

D. Appleton-Century Co., 1936.

955 Fisher Bldg.

-MSMS-

NO RETREAT FOR MEDICINE

The flame-lit skies of bombed British towns can
sometimes be seen at night from countries across the
Channel. America, too, hears the rumble of the War
God’s chariot and his hot breath is felt by_ each of us.
This is not strange when every paper in the land
carries banner headlines on war and on our defense
measures.

Reports are conflicting. The losses of the combatants
fluctuate like the stock market and figures are high
or low, depending on which side is telling the story.
Our thoughts are pulled this way and that by pro-
paganda. It is true that our sympathies lie with the
democratic nations, but do not make the mistake of
believing that therefore the dictator powers can have
no influence ovor our destiny. Propaganda, we are
told, is the most powerful weapon that can be wielded.
It sneaks and crawls into the very mind of man or
marches in to the tune of martial music. The demo-
cratic nations reach us by arousing sympathy; Hitler
and his unholy brethren inspire us with terror and
try to create the impression that they are invincible.
Many are prone to fall under the hypnotic sway of
such suggestions and might then assume that a struggle
is not even worth while.

Countless old legends are woven around a theme
similar to the story of Achilles’ heel. It is cornforting
to remember that there is always a weak point that
can be reached, and when poise is substituted for
hysteria we know that liberty must eventually conquer.

In a life-and-death struggle such as that now being
waged by England, activities must be restricted to the
bare necessities. Research goes on feverishly but in
the destructive field of war machinery. Medicine goes'
on too, and we are even told of great discoveries in
plastic surgery, wound therapy, and so forth, which
evolved during or as a direct result of the last World
War.

These too, however, must be considered as children
of necessity. The greatest part of medicine has to be
laid aside to be dusted off only after the peace treaty
has been signed.

In the meantime our American physicians must carry
a burden of responsibility not only for themselves but
for those of their profession who are homeless and
persecuted, for the harassed and overworked in the
war zone, for the dead, and for that vast uncounted
army of young men who would have become healers
if fate had not called upon them to become killers.

W’c must not permit the fire glow from England to
August, 1941

cause panic which will rout the ranks of medicine. We
must continue to perform our everyday tasks with as
much serenity as possible. We must not discard re-
search as useless in a mad world, for the day will
come to aid those who are torn and bleeding so that
when the first of destruction dies away, they may lift
high the bright flame of liberty that burns undying
in their hearts. — Pemisylvania Medical Journal, Feb.,
1941.

^MSMS

NURSING EDUCATION VS. NURSING CARE '

From a discussion at the midwinter session of the
Council of our Association, it is clear that the prob-
lem of nursing care is constantly gro-wing in serious-
ness and that unless remedial measures are promptly
instituted there is danger of a complete breakdown of
this indispensable service to the sick. Hospitals through-
out the state are threatened with serious handicaps in
their nursing care. The problem is particularly acute
for smaller institutions in the outlying districts.

The present dilemma may be traced to a number
of factors. The public health activities, the Red Cross,
the Visiting Nurse Associations, the school health serv-
ices, all have already absorbed, and are continuing to
draw, goodly numbers of graduates. The salaries, the
hours, and the nature of service offered by these posi-
tions are obviously more attractive than are the duties
connected with bedside routine in a home or in a
hospital.

The greatest contributing factor, however, must be
sought in deeper territory. The history of nursing
education in this country runs closely parallel to that
of medical education with this exception. A generation
ago there were 170 medical colleges in the United
States. As to training schools, well, there were almost
as many as there were hospitals. In Nebraska too,
until the reform beg^n it -was unthinkable for a
respectable hospital to deprive itself of a nurses’ train-
ing school. This statement is not made in a spirit
of sarcasm. Indeed, many graduates from these now
extinct training schools are today rendering excellent
bedside care to the people of our commonwealth.

With the change in trends of education in nursing,
the smaller schools have disappeared. Now only the
large and well endowed hospitals can keep up with
the rigid requirements and the academic equipment
necessary for an approved training school. The effort
to improve the standards of any profession deserves
praise, and as physicians we express our enthusiasm
over the attempt. In fact, we have helped in no small
measure to expand the curriculum.

“The recently graduated nurse is more interested in
an executive or administrative job than in actual nurs-
ing.” This statement was made in full sincerity by a
member of the Council, who for many years has
operated a well equipped but small hospital in the
state. The sentiment seemed to be general and prac-
tically unanimous that the modem R.N. considers
herself too well trained to administer “hypos” and
enemas.

It is not within the scope of this editorial to sug-
gest a solution to the problem. That the situation is
urgent the leaders in nursing education undoubtedly
appreciate. It is ardently hoped that our committees
appointed to study the dilemma will bring in some
tangible information that may promptly be utilized
as a basis for betterment of nursing care in Nebraska.
— Editorial from Nebraska State Medical Journal,
!March, 1941.

617

Editorial

MATURE JUDGMENT NEEDED

■ Unless intelligent judgment is used there will
always be difficulty in determining the divid-
ing lines between public health, preventive medi-
cine and curative medicine. Probably every cura-
tive procedure in medicine could be judged by
some to be a public health or a preventive meas-
ure and tacitly the function of the Department of
Health.

A number of instances have occurred recently
which indicate a broadening of this viewpoint
in defining public health and preventive meas-
ures and the part which should be played in
them by the group of health officers.

The Department of Health maintains a mobile
x-ray unit for the purpose of surveying certain
districts in which the incidence of tuberculosis is
a major problem. Primarily, it was meant for use
in those districts in which x-ray facilities were
lacking. In tjvo counties (which are adequately
equipped roentgenographically) the use of this'
unit has been offered to manufacturing plants at
a cost below that which could be met by private
roentgenologists. In each of these factories the
county health officer has felt a need for such
a survey existed. In one county the medical
profession refused to place its endorsement upon
this use and an appeal was taken to The Council
of the Michigan State Medical Society. The de-
cision was referred back to the county medical
society as being entirely within its own province
since the Department of Health had stipulated
that the consent of the local profession must be
obtained before the unit was used for this pur-
pose. In the other county the profession took no
formal action but a large majority of the mem-
bers individually offered no objections.

It seems to be the practice for the health officer/
to initiate this type of survey and since the sur-
vey is usually discussed with the industrialist be-
fore consulting the medical profession it puts the
onus of the decision on the practicing physician.
In the smaller counties this is embarrassing to
some members.

When the health officer has such a program
to suggest, the county medical society should
be consulted first and then the proposal should
be carefully weighed and studied, not alone

618

from the immediate effects upon the doctor
himself, but upvon the real need, from the
standpoint of preserving the health of the com-
munity, and also from the standpoint of the
preservation of private enterprise, which is
the foundation of the private practice of medi-
cine.

^MSMS

A GREAT MEETING

■ The Michigan State Medical Society will

hold its Seventy-sixth Annual Convention at
Grand Rapids, September 16, 17, 18, and 19.

Thirty out-of-state speakers, who are rec-
ognized leaders of their specialties, over a
hundred exhibits, and a sincere welcome
await you at Grand Rapids.

This second largest city of Michigan has been
most cooperative in caring for the crowds which
annually attend this instructive and entertain-
ing meeting. Its auditorium facilities are un-
surpassed and the hotels have been most con-
siderate of the desires and needs of the two
thousand doctors of medicine who attend. The
numbers of members who were disappointed by
the lack of proper facilities at Detroit last year
will be more than gratified by the entirely dif-
ferent attitude of the hotels in this year’s selected
city. There are several hotels in Grand Rapids
comparable to those in the very large metropoli-
tan areas. The auditorium is connected with
one of the hotels and furnishes the best arrange-
ment for exhibits which can be found in the
state.

Any description of Grand Rapids would be
very incomplete were one to omit mention of
the many beautiful parks in and about the city.
But chiefly is the city provided with wonderful
facilities for golf. There are no less than eleven
splendid golf courses in and around Grand Rap-
ids. In addition to the private country clubs such
as Cascade Hills, Highlands, Kent, and Blithe-
field there are a number of municipal and other
public links.

If you have not already made your reser-
vation for a room, do so immediately.

Jour. M.S.M.S.

Postgraduate Education in Michigan

A PHYSICIAN’S education is never done. It is
the penalty of medical leadership. Since every
doctor of medicine aspires to professional superiority,
voluntary postgraduate study has become a stern but
commonplace requisite of good practice today.

The Michigan State Medical Society, through its
Postgraduate Medical Education Committee, has
blazed a progressive trail in the training of Michi-
gan’s general practitioners. The high percentage of
attendance at its eight extramural, as well as its resi-
dent centers, speaks well for the medical competence
of doctors of medicine in this state.

In its constant efforts to improve and expand its
excellent program, the state society should give favor-
able consideration to a concentrated program at some
convenient center in the Upper Peninsula. More op-
portunity for continuation study in that vast area is
indicated ; the several hundred practitioners in the nine
Upper Peninsula county medical societies are most
desirous that an annual postgraduate day be inaugu-
rated.

When this center is established, the Michigan State
Medical Society will have covered the entire state with
a postgraduate program superior in quality and most
modern in execution.

President, Michigan State Medical Society

Michigan State Medical Society

Past Presidents 1866-1939

1866 — *C. M. Stock-well, Port Huron

1867 — *J. H. Jerome, Saginaw

1868 — *Wm, H. DeCamp, Grand Rapids

1869 — ^Richard Inglis, Detroit

1870 — *1. H. Bartholomew, Lansing

1871 — *H. O. Hitchcock, Kalamazoo

1872 — *Alonzo B. Palmer, Ann Arbor

1873 — *E. W. Jenk, Detroit

1874 — *R. C. Kedzie, Lansing

1875 — *Wm. Brodie, Detroit

1876 — * Abram Sager, Ann Arbor

1877 — *Foster Pratt, Kalamazoo

1878 — *Ed. Cox, Battle Creek

1879 — *George K. Johnson, Grand Rapids

1880 — *J. R. Thomas, Bay City

1881 — *J. H. Jerome, Saginaw

1882 — *Geo. W. Topping, DeWitt

1883 — *A. F. Whelan, Hillsdale

1884 — *Donald Maclean, Detroit

1885 — *E. P. Christian, Wyandotte

1886 — *Charles Shepard, Grand Rapids

1887 — *T. A. McGraw, Detroit

1888 — *S. S. French, Battle Creek

1889 — *G. E. Frothingham, Detroit

1890 — *L. W. Bliss, Saginaw

1891 — *George E. Ranney, Lansing

1892 — ^Charles J. Lundy (died before tak-

ing office)

*Geo. V. Chamberlain, Flint, Acting
President

1893 — *Eugene Boise, Grand Rapids

1894 — *Henry O. Walker, Detroit

1895 — ^Victor C. Vaughan, Ann Arbor

1896 — *Hugh McColl, Lapeer

1897 — * Joseph B. Griswold, Grand Rapids

1898 — * Ernest L. Shurly, Detroit

1899 — *A. W. Alvord, Battle Creek

1900 — *P. D. Patterson, Charlotte

1901 — *Leartus Connor, Detroit

1902 — *A. E. Bulson, Jackson

1903 — *Wm. F. Breakey, Ann Arbor

1904 — *B. D. Harison, Sault Ste. Marie

1905 — *David Inglis, Detroit

1906 — *Charles B. Stockwell, Port Huron

1907 — *Hermon Ostrander, Kalamazoo

1908 — *A. F. Lawbaugh, Calumet

1909 — *J. H. Carstens, Detroit

1910 — *C. B. Burr, Flint

1911 — *D. Emmett Welsh, Grand Rapids

1912 — *Wm. H. Sawyer, Hillsdale

1913 — *Guy L. Kiefer, Detroit

1914 — Reuben Peterson, Ann Arbor

1915 — *A. W. Hombogen, Marquette

1916 — Andrew P. Biddle, Detroit

1917 — Andrew P. Biddle, Detroit

1918 — Arthur M. Hume, Owosso

1919 — Charles H. Baker, Bay City

1920 — *Angus McLean, Detroit

1921 — *Wm. J. Kay, Lapeer

1922 — *W. T. Dodge, Big Rapids

1923 — Guy L. Connor, Detroit

1924 — *C. C. Clancy, Port Huron

1925 — *Cyrenus G. Darling, Ann Arbor

1926 — J. B. Jackson, Kalamazoo

1927 — Herbert E. Randall, Flint

1928 — Louis J. Hirschman, Detroit

1929 — J. D. Brook, Grandville

1930 — *Ray C. Stone, Battle Creek

1931— *Carl F. Moll, Flint

1932 — J. Milton Robb, Detroit

1933 — George LeFevre, Muskegon

1934 — *R. R. Smith, Grand Rapids

1935 — Grover C. Penberthy, Detroit

1936 — Henry E. Perry, Newberry

1937 — Henry Cook, Flint

1938 — Henry A. Luce, Detroit

1939 — Burton R. Corbus, Grand Rapids

*Deceased.

620

Jour. M.S.M.S. |

THE 7BTH A]^lVUAL MEETIIVG

GRAIVD RAPIDS - 1941

A. S. Brunk, M.D.
Detroit

Chairman- of The Council

L. Fernald Foster, M.D.
Bay City
Secretary

P. R. Urmston, M.D.
Bay City
President

OFFICIAL CALL

'^HE Michigan State Medi-
cal Society will convene in
Annual Session in Grand
Rapids, Michigan, on Septem-
ber 16, 17, 18, 19, 1941. The pro-
visions of the Constitution and
By-laws and the Official Pro-
gram will govern the delibera-
tions.

P. R. Urmston, M.D.,
President

A. S. Brunk, M.D.,
Chairman of The Council

O. D. Stryker, M.D.,
Speaker

Attest :

L. Fernald Foster, M.D.,
Secretary

O. D. Stryker, M.D.
Fremont

Speaker of House of
Delegates

Wm. a. Hyland, M.D.
Grand Rapids
T reasurer

August, 1941

H. R. Carstens, M.D.
Detroit

President-Elect

621

OUTLINE OF GENERAL ASSEMBLY PROGRAM
Seventy-sixth Annual Meeting, Michigan State Medical Society
Grand Rapids — September 17, 18, 19, 1941

Wednesday, September 17

Thursday, September 18

Friday, September 19

A. M.
9:30 to
10:00

Medicine

Russell L. Cecil, M.D.
New York City

Obstetrics (Maternal Health)
James R. McCord, M.D.
Atlanta, Georgia

ON THE

SEVEN SECTION PROGRAMS

General Medicine
A. R. Barnes, M.D.
Rochester, Minn

Surgery

Harry E. Mock, M.D.
Chicago

Obstetrics & Gynecology
Richard TeLinde, M.D.
Baltimore

Ophthalmology & Otolaryngology
Samuel Iglauer, M.D.
Cincinnati

Pediatrics

Harold K. Faber, M.D.

San Francisco

Dermatology & Syphilology
S. Wm. Becker, M.D.
Chicago

Radiology, Pathology, Anesthesia
Bernard H. Nichols, M.D.
Cleveland

10:00 to
10:30

Surgery

Elliott C. Cutler, M.D.
Boston

Medicine (Tuberculosis)
Charles E. Lyght, M.D.
Northfield, Minn.

10:30 to
11:00

VIEW EXHIBITS

VIEW EXHIBITS

11:00 to
11:30

Syphilology

Francis E. Senear, M.D.
Chicago

Medicine

V. P. Sydenstricker, M.D.
Augusta, Georgia

11:30 to
12:00

Gynecology

George W. Kosmak, M.D.
New York City

Pediatrics

James Gamble, M.D.
Boston

P. M.
12:00 to
12:30

Medicine (Mental Hygiene)
Lawrence Kolb, M.D.
Washington, D. C.

Obstetrics

Wm. E. Caldwell, M.D.
New York City

12:30 to
1:30

LUNCHEON
VIEW EXHIBITS

LUNCHEON
VIEW EXHIBITS

LUNCHEON
VIEW EXHIBITS

1:30 to
2:00

Anesthesia

Wesley Bourne, M.D.
Montreal

Ophthalmology
Alfred Cowan, M.D.
Philadelphia

Otolaryngology

D. E. Staunton Wishart, M.D.
Toronto

2:00 to
2:30

Surgery (Indus. Health)
A. J. Lanza, M.D.
New York City

Pathology

Shields Warren, M.D.
Boston

Dermatology

Carroll S. Wright, M.D.
Philadelphia

2:30 to
3:00

VIEW EXHIBITS

VIEW EXHIBITS

VIEW EXHIBITS

3:00 to
3:30

Pediatrics

Henry Poncher, M.D.
Chicago

Medicine

Chester S. Keefer, M.D.
Boston

Pediatrics (Child Welfare)
3:00 to 3:30

Borden S. Veeder, M.D.
St. Louis, Missouri

3:30 to
4:30

DISCUSSION
CONFERENCES
WITH GUEST
ESSAYISTS

DISCUSSION
CONFERENCES
WITH GUEST
ESSAYISTS

3:00 to 4:00
Medicine
C. A. Doan, M.D
Columbus

4:00 to 4:30
Surgery

Owen H. Wangenst^n, M.D.
Minneapolis

8:30 to
10:00

President’s Night
Biddle Oration
in Hotel Ballroom
Speaker:

Alphonse Schwitalla, S.J.
Dancing

Smoker

in Pantlind Hotel Ballroom
1

END OF
CONVENTION

622

Jour. M.S.M.S.

PRELIMINARY

- PROGRAM of GENERAL ASSEMBLIES

WEDNESDAY MORNING
September 17, 1941

First General Assembly

Black and Silver Ballroom — Civic Auditorium

A. S. Brunk, M.D., Presiding

L. Fernald Foster, M.D., and Gordon B. Myers, M.D.,
Secretaries

A. M.

9:30 “Arthritis — A Curable Disease?’’

Russell L. Cecil, M.D., New York City

B.A., Princeton University,
1902; M.D. Medical College
of Virginia, 1906; Sc.D.,
Medical College of Virginia,
1928. Entered Army in
June, 1917 ; served as Di-
rector of Laboratories at
Camp Upton, N. Y., and
Camp Wheeler, Georgia;
served at Army Medical
School and appointed Head
of Commission for Study of
Pneumonia by Surgeon Gen-
eral, 1917 to 1919. He is
now Professor of Clinical
Medicine, Cornell University
Medical School; Professor of
Medicine, Polyclinic Medical
Russell L. Cecil School and Hospital; he also
holds several other important
appointments. Doctor Cecil has published several
works on the subjects of pneumonia, arthritis and
rheumatism.

The curability of arthritis varies with the type.
Some of the specific forms, such as gonococcal or
meningococcal arthritis, are readily curable by
sulphonamide therapy. The arthritis of rheumatic
fever usually yields promptly to salicylates, but un-
fortunately the cardiac injury persists. Subacute
infectious arthritis often disappears permanently after
a focus of infection has been removed. Rheumatoid
arthritis is an extremely difficult disease to cure,
though a certain small percentage of these patients
do make a permanent and complete recovery. More
often the life history of the disease is characterized
by “ups and downs,” which go on indefinitely, with
periods of remission being followed by periods of
exacerbation. Gold salts offer more promise of
permanent relief in the treatment of rheumatoid
arthritis than any other remedy so far described.

Osteo-arthritis is also a chronic persistent ailment
which may yield readily to rest and physiotherapy,
but has a strong tendency to return when the joints
are overused. Gouty arthritis starts with acute at-
tacks from which the patient recovers completely
when treated promptly with colchicine. Chronic
gouty arthritis does not yield so quickly to remedial
agents.

Papers Will Begin and End on. Time!

Believing there is nothing which makes a scien-
tific meeting more attractive than by-the-clock
promptness and regularity, all meetings will op-
en exactly on time, all speakers will be required
to begin their papers exactly on time, and to
close exactly on time, in accordance with the
schedule in the program. All who attend the
meeting, therefore, are requested to assist in
attaining this end by noting the schedule care-
fully and being in attendance accordingly. Any
member who arrives five minutes late to hear
any particular paper will miss exactly five min-
utes of that paper !

10:00 “Acute Appendicitis — A Twenty-five Year
Study’’

Elliott C. Cutler, M.D., Boston
(Stanley O. Hoerr, M.D., Boston, Associate
in Study)

A.B., Harvard, 1909; M.D.,
Harvard Medical School,
1913; Honorary Doctorate,
University of Strasbourg,
1938. Served in World War
as Major, Medical Corps; Lt.
Colonel, Medical Corps Re-
serve, since 1924; decorated
with Distiiiguished Service
Medal. Chairman, Depart-
ment of Surgery, and Direc-
tor of Laboratory of Surgical
Research, Harvard, 1922-24;
Professor of Surgery, West-
ern Reserve University
School of Medicine, 1924-32;
Consulting Surgeon, New
England Peabody Home for
Crippled Children, 1932 to
r c- TT 1 present; Moseley Professor

of Surgery, Harvard, 1932 to present; Surgeorp-in-
Lhtef, Peter Bent Brigham Hospital. Doctor Cutler is
a member of many medical and social organisations.

Elliott C. Cutler

The deaths from acute appendicitis occur, as is
well known, in patients in whom peritonitis has
already developed when they first reach the hos-
pital. Early diagnosis and avoidance of catharsis
through education both of the laity and the profession
remains as important today as it was twenty-five
years ago. Today, however, strict attention to the
details of pre-operative and postoperative management
including fluid and electrolyte balance, use of cheml
otherapy, and gastro-intestinal syphonage is saving
lives that would previously have been lost. Hospital
morbidity in severe cases is cut down by the general
use of the McBurney incision, less frequent drainage
of the peritoneal cavity, and partial closure of the
wound by leaving the skin open.

10:30 INTERmSSION TO VEEW THE EXHIBITS

11:00 “Serologic Aspects of Syphilis’’

Francis E. Senear, M.D., Chicago

B.S., University of Michi-
gan, 1912, M.D., 1914. Pro-
fessor and Head of Depart-
ment of Dermatology, Uni-
versity of Illinois College of
Medicine since 1923. Mem-
ber of Serologic Evaluation
Committee, 0. S. Public
Health Service, American
Medical Association, Chicago
Dermatological Society, So-
ciety of Investigative Der-
matology, the American
Academy of Dermatology and
Syphilology, the American
Dermatological Association.

The multiplicity of sero-
diagnostic tests fo'r syphilis
Francis E. Senear is discussed ■ together with a
review of the studies carried
out on an international and national scale in an at-
tempt to determine the best available sero-diagnostic
methods. The limitations of the diagnostic tests for
syphilis are discussed with a consideration of these
phases in which the serologic reaction is apt to be
negative in the presence of disease and with a con-
sideration of the other disorders which are capable
of giving rise to biologic false positive reactions.
Methods offered to distinguish between the true
syphilitic reaction and the biologic false reaction are
considered and their usefulness is discussed. The
significance of positive cord blood findings is dis-
cussed and the significance of changes in the strength
of the reaction of the cord blood are considered.
The paradoxical false positive reactions occurring in
individuals with no signs of syphilis and with no
other disease to account for them are of great
significance and are met with sufficient frequency to
make their recognition a matter of great importance
to the practitioner.

August, 1941

623

PROGRAM SEVENTY-SIXTH ANNUAL MEETING

11:30 “The Medical and Other Implications
Which Relate to An Aging Female Popula-
tion’’

George W. Kosmak, M.D., New York City

WEDNESDAY AFTERNOON
September 17, 1941

Second General Assembly

A.B., M.D., Columbia College, 1894. College of
Physicians, and Surgeons, 1899. Attending Surgeon,
Lying-In Hospital of New York, 1904-1926. Editor
and founder, American Journal of Obstetrics and
Gynecology, 1920 to date, editor of preceding publica-
tion, 1909-1919. Member, American Gynecological So-
ciety, American Association of Obstetricians and
Gynecologists, Diploijiate of American Board. Con-
sultant in obstetrics fio several hospitals; Federal
Children’s Bureau, New York State Department of
Health, etc. Author of book, ‘‘Toxemia: of Pregnancy”
(1933), and of numerous articles in medical and lay
journals on obstetric topics.

It is an acknowledged fact that the average span of
life has increased from about thirty-six years in 1850
tO' over sixty years in 1930 and will probably reach
seventy years or more in 1960. The possible causes
for this will be discussed and attention called to the
associated medical and social problems. Undoubtedly
better economic conditions, reduced hazards to life
from improved sanitation, the lessening complications
of child-bearing, and increased medical knowledge have
constituted important contributing factors. We are
faced, however, with the question of dependence by
the older upon the younger groups and by the need of
a closer study of the degenerative diseases which are
manifest in the aged. Society and medicine must
combine to study and to solve these problems.

12:00 “The Needs and Possibilities of Research
in Mental Disease’’

Lawrence Kolb, M.D., Washington

M.D.. University of Mary-
land, 1908. Assistant Sur-
geon General, U. S. Public
Health Sendee, Washington,
D. C., in charge of the Di-
vision of Mental Hygiene.
Fellow, American College of
Physicians, American Medical
Association, and American
Psychiatric Association. Mem-
ber, National Committee for
Mental Hygiene, American
Association for the Advance-
ment of Science, Research
Council on Problems of
Alcohol, Academy of Medi-
cine of Washington, D. C.,
American Prison Association,
Lawrence Kolb Southern Medical Associa-
tion, Medical Society of St.
Elisabeth’s Hospital, Kentucky Psychiatric Association.
Trustee, William Alanson White Psychiatric Founda-
tion.

Recent advances in medical knowledge suggest lines
of approiach to the study of the fundamental basis
of mental disease. These studies should include
biology, biochemistry, neurophysiology, pathology,
endocrinology, morphology, psychology, etc., as these
subjects may have a bearing on mental disease. Such
studies should be supplemented by extensive field
studies into the social and environmental factors.
Close cooperation between the Federal and State
governments and agencies in a position to carry on
research is needed to reap the fullest benefit from
available resources.

P. M.

12:30 End of First General Assembly
12:30 I/uncheon

Black and Silver Ballroom — Civic Auditorium

Vernor M. Moore, M.D., Presiding
L. Fernald Foster, M.D., and Robert G. Laird, M.D.,
Secretaries

P. M.

1:30 Officiis in Anesthesia’’

Wesley Bourne, M.D., Alontreal

M.D., C.M., McGill Uni-
versity, 1911; M.Sc., McGill,
1924; F.R.C.P., Canada,

1931; D.A. (R.C.P. & S.
Eng.), 1938. First Hickman
Medallist, Roy. Soc. of Medi-
cine, 1935. Lieutenant-Colo-
nel, R.C.A.M.C. Lecturer
(Anesthesia) Department of
Pharmacology, McGill Uni-
versity. _ Author of many
publications on anesthesia.
Member of the American
Society for Pharmacology
and Experimental Therapeu-
tics.

Although duties prescribed
by justice are to be given
precedence, and nothing
ought to be more sacred, yet
in the pursuit of knowledge, we should feel obliged
to apply our wisdom to the service of humanity. We
oiught to consider ourselves bound to teach and train
those who are desirous of learning. In such manner
the benefits of anesthesia may be extended to those
with whom we are united by the bonds of society.
With increasing concerted effort, by cooperation
between the laboratory worker and the clinician,
anesthesia has improved, and the public is recognizing
the need and importance of good anesthesia.

2:00 “Medical Service in Small Industries’’

A. J. Lanza, M.D., New York City

M.D., George Washington
University Medical School,
19u6. Served in the United
States Public Health Service
from 1907 until 1920. During
part of this time was detailed
as Chief Surgeon of the
United States Bureau of
Mines, and later, Head of
the Office of Occupational
Diseases in the Public Health
Service. Mostly engaged in
Field work doing investiga-
tions in industrial hygiene.
Conducted the first studies in
this country on silicosis.
1920 became Medical Director
of the Hydraulic Steel Com-
A. J. Lanza pany of Cleveland. In 1921

was appointed a special Staff
member of the International Health Board of the
Rockefeller Foundation, and was detailed as Adviser
in industrial hygiene for the Commonwealth Govern-
ment of Australia. In 1926 was appointed Assistant
Medical Director of the Metropolitan Life Insurance
Company. At present time is a member of the
Council of the American Medical Association on
Industrial Health. Member of the Sub-com'tmttee on
Industrial Health of the Health and Medical Com-
mittee, Federal Security Agency. Chairman of the
Medical Committee of the Air Hygiene Foundation.

The great bulk of all wage earners are employed
in small plants, and 97 per cent of all manufacturing
plants employ fewer than 250 men. The problem of
providing adequate medical and health service for
American wage earners is, therefore, essentially a
problem of devising a program that will fit the small

Jour. M.S.M.S.

624

PROGRAM SEVENTY-SIXTH ANNUAL MEETING

industry. While occupational diseases are a definite
factor in the industrial health situation, the loss in
working days is due to non-occupational hazards. The
American Medical Association, State Medical Societies
and other Medical Organizations, are taking cognizance
of this problem, as well as official agencies, like the
Public Health Service, and non-official agencies, such
as the Air Hygiene Foundation. It is obvious that
health and medical service in these small plants, where
the majority of American workmen are employed,
will be given by local physicians serving industry on
a part-time basis. Here is an opportunity, and the
responsibility of the medical profession. The difference
between medical service in a small plant and in a
large one should be a difference in quantity only,
and not in quality. Then, if only a small reduction
can be made in absences in industry, it will never-
theless accompany a great economic saving and be a
contribution of inestimable value with the production
problem that faces American industry at the present
time.

2:30 INTERMISSION TO VIEW THE EXHIBITS

3:00 “Hemorrhage in the Newborn”

Henry Poncher, AI.D., Chicago

M.D., University of Mich-
igan, 1927, Associate Pro-
fessor of Pediatrics, College
of Medicine, University of
Illinois, Attending Physician,
Cook County Hospital, Physi-
cian in charge of Pediatric
Service, Research and Edu-
cational Hospitals of Illinois.
Licentiate of American Board
of Pediatrics.

The newborn may po-

tentially hemorrhage from a
variety of causes. Practically,
however, trauma alone or

minimal trauma in the pres-
ence of a disturbed clotting
mechanism are the ones that
Henry Poncher the practicing physician en-
counters most commonly in
his daily work. The minimizing of the traumatic

factor alone is outside the scope of this presentation.
The part that disturbed coagulability of the blood

plays in conditioning hemorrhage of traumatic origin
or giving rise to spontaneous bleeding will be dis-
cussed. The recent work on prothrombin and vitamin
K will be reviewed from the standpoint of its
practical implications.

3:30 Discussion Conferences with Guest Essay-
ists

5:00 End of Second General Assembly

-MSMS-

t

f

\

s

f

y

I

h

DISCUSSION CONFERENCES

Wednesday, September 17
Thursday, September 18
3:30 to 4:30 p. m.

WITH THE GREAT ESSAYISTS

Eleven discussion conferences with a differ-
ent chairman in each subject, each day — leaders
of outstanding- ability in their specialty. Here
the doctor will have a chance to ask those
questions which have bothered him and to
hear discussed and answered other questions
of value to him in his daily practice.

A RARE OPPORTUNITY

THURSDAY MORNING
September 18, 1941

Fourth General Assembly

Black and Silver Ballroom — Civic Auditorium

C. E. Umphery, M.D., Presid’ng,

L. Fernald Foster, ;M.D., and Roger V. Walker, M.D.,
Secretaries

A. M.

9:30 “Some Obstetric Opinions”

James R. McCord, M.D., Atlanta

M.D., Jefferson Medical
College, 1909; Professor of
Obstetrics and Gynecology,
Eniory School of Medicine;
Diplomate American Board of
Obstetrics and Gynecology.

The paper is, in the main,
an expression of the author’s
own personal philosophy of
obstetrics and a brief dis-
cussion concerning the
management of quite a few
obstetric difficulties. Practi-
cally all of the opinions are
personal and have as their
background Dr. McCord’s
vast obstetric experience.

10:00 “Some Educational Aspects of Diagnosing
Tuberculosis Early”

Charles E. Lyght, M.D., Northfield, Minnesota

M.D., C.M., Queen’s Uni-
versity Faculty of Medicine,
(Canada), 1926. Department
of Student Health, Uni-
versity of Wisconsin, Madi-
son, 1927-36; Director, 1922-
36; Associate Professor of
Clinical Medicine, University
of Wisconsin Medical School.
Professor of Health and
Physical Education, and

Director of _ the Student

Health Service, Carleton
College, Northfield, Minne-
sota, 1936 to date. Staff
of Northfield City Hospit^
and Allen Memorial In-
firmary. Fellow of the

Ch.vrles E. Lyght American College of Physi-

cians. Member of several
professional and scientific societies, including the

Minnesota Trudeau Medical Society and Sigma Xi.
Past President of the North Central Section, American
Student Health Association, and, since 1936, Chatr-

man of the Tuberculosis Committee, A.S.H.A.

Publications, in addition to a weekly column: “Lyght
on Health,” have been mainly in the fields of clinical
medicine, tuberculosis control and student health.

Prognosis in tuberculosis depends on a combination
of factors, chief favorable one being early diagnosis.
Mass search has produced startling results in driving
tuberculosis from first down to seventh among death
causes. Individual practitioners must not decide that
modern methods work only in community surveys or
are the implements of specialists. Nor must we
strengthen techniques only during periodic national
emergencies. Tuberculin test, x-ray, _ with painstaking
clinical, laboratory and epidemiological follow-up of
patients and contacts are available to every physician.
To wait for consumptive symptoms or to rely primarily
on the stethoscope is to diagnose late — inexcusable in
the light of common knowledge and professional
obligation.

August, 1941

625

PROGRAM SEVENTY-SIXTH ANNUAL MEETING

10:30 INTERMISSION TO VIEW THE EXHIBITS

11:00 “Factors in Deficiency Disease’’

V. P. Sydenstricker, M.D., Augusta, Ga.

M.D., Johns Hopkins, 1915. Intern, and assistant
resident physician, Johns Hopkins Hospital, 1915-17.
Medical Corps, U. S. Army, 1917-19. Professor of
Medicine, University of Georgia School of Medicine,
1923 to present.

The background of clinical avitaminoses will be dis-
cussed from the standpoint of dietary inadequacy and
also of conditioning disorders in individuals taking
apparently adequate diets. Various clinical patterns
of deficiency diseases will be presented with particu-
lar reference to the more common but often unrecog-
nized syndromes. The rationale of treatment of both
the acute and chronic deficiency diseases will be con-
sidered, with particular emphasis on the importance of
multiple vitamin therapy.

11:30 “Pathogenesis of Acidosis and Alkalosis’’

James L. Gamble, M.D., Boston

A.B., Leland Stanford
University, 1906, M.D.,

Harvard Medical School,
1910, S. M. (hon.) Yale Uni-
versity, 1930. Teaching and
investigation in Department
of Pediatrics, The Harvard
Medical School (1915-22).
Professor of Pediatrics, 1930
to date. Member American
Pediatric Society, American
Academy of Pediatrics, As-
sociation of American Physi-
cians, Amer’can Society of
Biological Chemists.

Stability of the reaction of
extracellular fluid depends on
preservation of the normal
James L. Gamble values for carbon>c acid and
bicarbonate. Acidosis, or
alkalosis, is almost always the result of change in
bicarbonate rather than carbonic acid. Change in
bicarbonate is always the result of change in other
parts of the electrolyte structure. Illustration of
such change caused by various conditions of disease
is presented. The very frequent presence of volume
change (dehydration) along with change in reaction
is emphasized.

P. M.

12:00 “The Physiology and Management of the
First Stage of Labor’’

Wm. E. Caldwell, M.D., New York City

M.D., New York Uni-
versity and Bellevue Hospital
Medical School, 1904; Pro-
fessor clinical obstetrics and
gynecology and associate
director Sloane Hospital,
Columbia University, since
1927. Served as Captain
Medical Corps, U. S. A.,
1918. Fellow, American Col-
lege of Surgeons; New York
Obstetrical Society; American
Gynecological Society; Ameri-
can Gynecologic Club; Sigma
Xi; Nu Sigma N-u; Century
Club. Contributed many
brofessional articles to Ameri-
can Journal of Obstetrics and
Wm. E. Caldwell Gynecology and other jour-
nals. Received Honorary
Degree as Doctor of Public Health, New York City.

We will discuss the manner in which the lower
uterine segment retracts over the piston; the formation
of the contraction ring and its significance; and the
variable mechanism indicated in the individual pelvis.

We will point out how few cases there are of
absolute disproportion, but how the shape of the
inlet, the mid-pelvis or even the outlet modifies both j
the first and second stage. The changes in the shape
of the child’s head by molding will be emphasize./
We will discuss the value of clinical examinations in 'i
the patient, what knowledge can be obtained, by i
vaginal and rectal examinations. Including the pos-
sibility _ of assisting the mechanism of labor by ma-‘i
nipulation from below in some cases; the necessity of ;
complete retraction of the soft parts before operative
procedure can be undertaken; and the importance of j
recognizing early the best method of safely delivering ■
the child.

P. M.

12:30 End of Fourth General Assembly

12:30 Luncheon

MSMS

THURSDAY AFTERNOON
September 18, 1941

Fifth General Assembly

Black and Silver BaUroom — Civic Auditorium

Wilfrid Haughey, M.D., Presiding
L. Fernald Foster, M.D., and Frank Murphy, M.D.,
Secretaries

P. M.

1:30 “Some Observations on the Use of Glasses’’

Alfred Cowan, M.D., Philadelphia

M.D., Medico Chirurgical ,
College, Philadelphia, 1907.
At present Professor of
Ophthalmic Optics, Graduate
School of Medicine, Uni- ;
versity of Pennsylvania;
Ophthalmologist to Philo- fi
delphia General Hospital; f
Supervising Opthalmologist,
Department of Public As- i
sistance. Commonwealth i
P ennsylvanta; Consulting j
Ophthalmologist, Council for 1
the Blind, Commonwealth of E
Pennsylvania; Ophthalmol- J
ogist to Pennsylvania Work- 1
ing Home for Blind Men, I
Philadelphia; Author of “An J
Alfred Cowan Introductory Course in Oph- t

thalmic Optics’’ and of "Re- i
fraction of the Eye," and a number of articles ^ on 1
ophthalmological subjects; a member of the American I
Ophthalmological Society; American Academy of i
Ophthalmology and Otolaryngology ; College of Physu I
dans, Philadelphia, and others. I

This presentation is offered with the hope that it |
will suggest to the general physician a simple way j
of describing certain physiologic optical principles to )
their patients — the purposes for which glasses are
used, when they should be worn and when they are
not worthwhile.

The normal eye is an image-forming optical instru-
ment with a remarkable range of adaptability. Clear, ;
comfortable vision depends primarily on a sharp ,
image which must be formed exactly on the surface
of the retina without undue effort of accommodation.

In a refractive error — myopia, hypermetropia, as-
tigmatism— the correct lens, when placed before the '
eye, changes the final direction of the rays of light
so that on entering the eye they will be imaged on
the retina. This is equivalent to placing an object at
the exact position for which the eye is adapted.

A refractive error is not a disease, nor can it be
produced by work ng under unfavorable conditions.
Every person must eventually become presbyopic.

Jour. IM.S.M.S. .

626

PROGRAM SEVENTY-SIXTH ANNUAL MEETING

2:00

2:30

.3:00

3:30

5:00

PRELIMINARY

PROGRAM of SECTIONS

FRIDAY MORNING
September 19, 1941

“The Resi)onse of Tumors to Radiation”

Shields Warren, M.D., Boston

B.S., Boston University ;
M.D., Harvard Medical
School, 1923; Assistant Pro-
fessor of Pathology, Harvard
Medical Schoof 1936 to
date; Director, Massachusetts
State Tumor Diagnosis Serv-
ice, 1928 to date; Pathologist
to New England Deaconess
Hospital, 1927 to date, C. P.
Huntington Memorial Hospi-
tal, 1928 to date. New Eng-
land Baptist Hospital, 1928
to date, Pondville State
Hospital, 1928 to date; Chair-
man, Cancer Committee,
Massachusetts Medical Soci-
ety; Vice President, Ameri-
can Association for Cancer
Research.

The response of tumors to radiation is based on
the sensitivity of the type cell, the character of the
supporting tissues, and the effect on the normal issues
of the host. Depending on their response to radiation
tumors _ may be classed as radio-sensitive, radio-
responsive, and radio-resistant. Radio-resistance may
be acquired following radiation therapy.

The tissue reactions for a given dose are fairly
constant and characteristic regardless of minor varia-
tions in wave length. Recently irradiated tissue is
very susceptible to infection.

INTERMISSION TO VIEW THE EXHIBITS

SECTION ON GENERAL MEDICINE

Chairman: T. I. Bauer, M.D., Lansing
Secretary: Gordon B. Myers, M.D., Detroit

Ballroom — ^Pantlind Hotel

9:30 “The Differentiation Between Malignant
and Benign IJlcerating Lesions of the Stom-
ach”

H. M. Pollard, M.D., Ann Arbor
Wm. C. Scott, M.D., Ann Arbor

A. M.

9:00 “The Differential Diagnosis of Abdominal
Pain”

Milton R. Weed, M.D., Detroit

“Recent Advances in Chemotherapy of In-
fectious Diseases”

Chester S. Keefer, M.D., Boston

M.D., Johns Hopkins Uni-
versity School of Medicine,
1922; Director, Evans Me-
morial, Massachusetts Me-
morial Hospitals; Wade Pro-
fessor of Medicine, Boston
University School of Medi-
cine, also Professor of Medi-
c i n e. Harvard Medical
School; Diplomate, American
Board Internal Medicine.

The treatment of infectious
diseases with the sulfonamide
group has advanced remark-
ably in the past few years.
New compounds are being
developed and tested every
year so that there are at
least five effective agents
available at present. Each
one of these sulfonamide derivatives has its special
field of usefulness, and will be discussed in this paper.
One recent study with sulfadiazine and sulfaguanidine
will be presented. In addition to the discussion of the
sulfonamides, our experience in the treatment of local
infections with “gramicidin,” the extract of a soil
bacillus, will be reviewed.

Chester S. Keefer

Discussion Conferences with guest essay-
ists.

10:00 “Problems in the Differential Diagnosis of
Coronary Artery Disease”

A. R. Barnes, M.D., Rochester, Minnesota

M.D., Indiana University
School of Medicine, 1919;
Professor of Medicine, Mayo
Foimdation for Medical Edu-
cation and Research, Uni-
versity of Minnesota, and
Chief of a Section in Medi-
cine, The Mayo Clinic,
Rochester, Minnesota; Diplo-
mate, American Board of
Internal Medicine.

So much has been said and
written on the subject of
coronary sclerosis that there
is some evidence of a tenden-
cy to make the diagnosis
more frequently than the
facts warrant. Unfortunately,
A. R. Barnes the syndrome of angina pec-

toris is a diagnosis that has
to be made on the basis of the patient’s symptoms
and much skill and experience is required in arriving
at the diagnosis. There is a tendency to_ allow the
electro-cardiogram to influence this diagnosis, unduly.
There are other clinical conditions, such as peri-
carditis, pulmonary embolism, cholecystic disease and
diaphragmatic hernia, which may simulate the pain
of coronary artery disease very closely. _ This dis-
cussion will concern itself with the essential clinical
features of coronary disease and its differential
diagnosis from the clinical conditions mentioned.

End of Fifth General Assembly

10:30 “Clinical Use of the Diuretics”

PRESIDENT’S NIGHT
(Third General Assembly)

Wednesday, September 17, 8:30 p. m.

Ballroom, Pantlind Hotel
Brief prog'ram, followed by
dancing, floor-show and entertainment.

SMOKER

(Sixth General Assembly)

Thursday, September 18, 9:00 p. m.

Ballroom, Pantlind Hotel
A joyous night for members onlv.

Richard H. Lyons, M.D., Eloise

11:00 “Treatment of Pyelonephritis”

Muir Clapper, M.D., Detroit

11:30 “Useful Drugs in the Treatment of
Asthma”

John M. Sheldon, M.D., Ann Arbor

12:00 Election of Officers

August, 1941

627

PROGRAM SEVENTY-SIXTH ANNUAL MEETING

SECTION ON SURGERY

Chairman ; O. H. Gillett, M.D., Grand Rapids
Secretary ; Roger V. Walker, M.D., Detroit

Black and Silver Ballroom — Civic Auditorium
8:30 A. M.

SYMPOSIUM ON TRAUMATIC SURGERY

Despite general acceptance of early operative treat-
ment, the mortality still continues high, because of
the serious threat to life, occasioned by spillage of
intestinal content into the peritoneal cavity.

In civil practice, one of the greatest difficulties
is determination of whether or not blunt trauma has
ruptured a hollow viscus. Tears in solid viscera,
such as liver or spleen, may be treated conservatively,
if hemorrhage is not alarming. Bleeding stops fre-
quently spontaneously. Ruptures of hollow viscera
must be closed if the patient is to have a chance of
survival.

“Management of Skull Fractures”

“Treatment of Shock from War Injuries”

Harry E. Mock, M.D., Chicago

Henry H. Harkins, M.D., Detroit

M.D., Rush Medical Col-
lege, 1906. Associate Pro-
fessor of Surgery North-
western University Medical
School; Senior Surgeon St.
Lukes Hospital, Chicago;
Fellow American Board of
Surgery, American College of
Surgeons; Chicago Surgical
Society; Chicago Institute of
Medicine; American Associa-
tion of Surgery of Trauma,
and others. Author of many
<^urgical subjects. Exhibitor
in the Scientific Exhibits of
the American Medical As-
sociation from 1931 to 1938
on the subject of Skull
Fractures and Craniocerebral
Injuries.

Craniocerebral injuries in the United States occur
to the extent of more than half a million victims a
year. Approximately 65 per cent of the deaths

resulting from skull fractures occur in the first
twenty-four hours following the injury. The wide-
spread distribution and the early occurence of death
will always make this a problem for the general
physician and surgeon. The author collected and
analyzed 3,300 cases of consecutive proved skull

fractures from 1929 through 1934. The mortality rate
varied from 25 per cent to 49 per cent during that
period. The last ten years has brought forth abundant
teaching of better management. Has it reduced the
mortality rate? Is there room for still further im-
provement? These and other questions are answered
in the author’s second nation-wide survey of 3,200
co-nsecutive proved skull fractures.

“Lacerations of the Head and Face”

Ferris N. Smith, M.D., Grand Rapids

“Choice of Anesthesia in Emergency
Surgery”

Wesley Bourne, M.D., Montreal

The general principles of anesthesia are not affected
by the circumstances of emergency, yet the individual
may frequently be most urgently in need of the
best attention known to anesthesia. Whatever is done
should suit the general condition as well as the
surgical requirements of the case. When shock is
present, there must be the greatest circumspection
and the least possible interference until the circulation
is improved. The relative advantages of the drugs
and the methods of their administration are discussed
under the groupings of regional and general anesthesia,
showing the appropriate places of local infiltration,
of nerve block and of spinal anesthesia, and too, those
for inhalation and intravenous anesthesia.

“Early Care of Compound Fractures”

Carl E. Badgley, M.D., Ann Arbor
“Management of Abdominal Injuries”

Owen H. Wangensteen, M.D., Minneapolis

World War Number Two has focused attention
upon the subject of trauma sharply again. Whereas
the mortality of abdominal injuries in war has always
been high, statistically, the incidence of abdominal
injuries, as compared with the more frequent injuries
of extremities and head, has not been great. World
War Number One settled, once and for all, the
importance of early closure of perforating wounds of
the hollow abdominal viscera. Theretofore, the con-
servative management of bullet wounds of the intestine
had been advocated by many military surgeons.

Election of Officers

MSMS

SECTION ON OBSTETRICS AND GYNECOLOGY

Chairman : Clair E. Folsome, M.D., Ann Arbor
Secretary: Robert S. Kennedy, M.D., Detroit

Grill Room — Pantlind Hotel

A. M.

9:30 “Facilities and Practices in Licensed Ma^
temity Hospital and Maternity Homes in
Michigan”

Alexander M. Campbell, M.D., Grand Rapids

9:50 “The Use and Abuse of Stilbesterol in
Gynecologic Practice”

Allan C. Barnes, M.D., Ann Arbor

10:40 “The Dangers of Breech Delivery”

Ward F. Seei.ey, M.D., Detroit
R. S. SiDDALL, M.D., Detroit

11:00 “Therapy of the Estrogens”

Richard W. TeLinde, M.D., Baltimore

A.B., University of IVis-
consm, 1917, M.D., Johns
Hopkins University, 1920.
Professor of Gynecology,
Johns Hopkins University.
Chief Gynecologist, Johns
Hopkins Hospital. Visiting
Gynecologist, Union Memo-
rial Hospital, Church Home
and Infirmary and Hospital
for Women of Maryland.

Attention is called to the
many abuses in endocrine
therapy in general and a
warning is given to use
hormones only when there is
a sound physiological basis
for treatment. The results
Richard W. TeLinde at the author’s clinic in the
treatment of certain condi-
tions in which he has had special experience are
considered. The technique of the treatment of
gonococcal vaginitis with estrogenic suppositories, both
natural and synthetic, is discussed. The treatment
of menopausal symptoms by the natural hormones
and stilbestrol is considered. Finally, a new technique
for the administration of pellets of crystalline estrone
for prolonged relief of menopausal symptoms is
given in detail.

11:30 Election of Officers

12:00 Luncheon

628

Jour. M.S.M.S.

PROGRAM SEVENTY-SIXTH ANNUAL MEETING

SECTION ON OPHTHALMOLOGY AND
OTOLARYNGOLOGY

Chairman: Robert H. Fraser, M.D., Battle Creek
Vice Chairman: A. S. Barr, M.D., Ann Arbor
Secretary: Robert G. Laird, M.D., Grand Rapids

Vice Secretary: Arthur E. Hammond, M.D., Detroit

OPHTHALMOLOGY
Room “F” — Civic Auditorium

A. M.

9:30 “Uveitis”

Alfred Cowan, M.D., Philadelphia

The various parts of the uveal tract are so' inti-
mately related that hardly, if ever, is any one part
affected without involvement of all or nearly all of
the whole tract. More and more, since the general
use of the slit lamp and corneal microscope, is this
observed; so much so that specific diagnoses as
iritis, cyclitis, or irido cyclitis are seldom well justi-
fied. The first evidence of any insult to the iris or
ciliary body is a disturbance of the pigment. Often
we see evidence of uveal change, especially disturb-
ance of the pigment, which is hard to classify as
either a noninflammatory degenerative process or a
low grade, chronic uveitis. The etiolog’c factors
in these cases are nearly always baffling. So fre-
quently do we see such conditions that it is felt
that many which are diagnosed as primary glaucoma
are in reality cases of uveitis with secondary glau-
coma.

10:10 Discussion — 20 Minutes

10:30 “Dendritic Keratitis”

John O. Wetzel, M.D., Lansing

10:50 Discussion — 10 Minutes

11:00 “Management of Traumatic Injuries to the
Eyelids and Globe”

Gordon L. Witter, M.D., Port Huron

11:20 Discussion — 10 Minutes

11:30 “Chemical Injuries”

Melvin H. Pike, M.D., Midland

11:50 Discussion — 10 Minutes

12:00 “Some Uses of Chemotherapy in Ophthal-
mology”

Parker Heath, M.D., Detroit

P. M.

12:20 Discussion — 10 Minutes

OTOLARYNGOLOGY
Room “G” — Civic Auditorium

A. M.

9:00 “Mistakes Made in the Diagnosis and Esti-
mation of Deafness”

D. E. S. WiSHART, M.D., Toronto, Ontario

9:30 Discussion — 10 Minutes
August, 1941

9:40 “Acute Suppuration in the Spaces of the
Neck” and Motion Picture Demonstration:
“Approaches to the Surgical Spaces of the
Neck.”

Samuel Iglauer, M.D., Cincinnati

M.D., Ohio Medical Col-
lege, 1898; F.A.C.S.; Profes-
sor of Otolaryngology, Col-
lege of Medicine , University
of Cincinnati; Director of
Otolaryngology, Cincinnati
General Hospital, Children’ s
Hospital, and Jewish Hos-
pital; member, American
Laryngological, Rhinological,
and _ Otological Society,
American Broncho-Esophago-
logical Assn., American
Laryngological Assn., Ameri-
can Academy of Ophthalmol-
ogy and Otolaryngology.

During recent years a
great deal of exa^ct attention
has been given to deep in-
fections in the neck. These
infectious processes may localize in the lymph glands,
in the “spaces” of the neck, or occasionally within
the veins. The anatomic spaces contain loose dis-
tensible areolar connective tissue. The spaces are
limited by tough, fibrons layers (fascia) or by
muscles or viscera The spaces most commonly in-
volved are: 1. Peripharyngeal; 2. Retropharyngeal;
3. Parapharyngeal (Pharyngo-maxillary) ; 4. Perie-
sophageal (Mediastinitis) ; 5. Submental (Ludwig’s

Angina) ; 6. Septic thrombophlebitis (jugular) may
occur as a complication.

The signs and symptoms of infection in each space
will be enumerated, and the surgical approach to
each space will be briefly described.

Discussion and Bibliography Question Box
(by request)

11:30 “Carcinoma of the Mastoid. Case report”

Harvey E. Dowling, M.D., Detroit

11:50 “Treatment of Hemorrhage in Otolaryn-
gologic Practice”

James E. Croushore, M.D., Detroit

P. M.

12:10 Discussion of papers by Drs. Dowling and
Croushore

12:30 Section Luncheon, Pantlind Hotel

Election of Ofl8.cers of Section on
Ophthalmology and Otolaryngology
Short Business and Medical Economics
Session.

“Problems of Distribution of Ophthalmo-
logic Care”

Ralph Pino, M.D., Detroit

MSMS

SECTION ON PEDIATRICS

Chairman: Harry A. Towsley, M.D., Ann Arbor
Secretary : Leon DeVel, M.D., Grand Rapids

Swiss Room — ^Pantlind Hotel

A. M.

9:00 Case Report: “Tumor of Adrenal Cortex in
an Infant of Seventeen Months” Color
Photography and Autopsy Findings

Rockwell M. Kempton, M.D., Saginaw
Oliver W. Lohr, M.D., Saginaw

9:15 Panel Discussion: “Diarrhea in Infancy”

Chairman — Charles F. McKhann, M.D., Ann
Arbor

Discussants — James Wilson, M.D., Detroit
A. Morgan Hii.l, M.D., Grand Rapids
Wyman C. C. Cole, M.D., Detroit
Mark Osterlin, M.D., Traverse City
Warren Wheeler, M.D., Lansing

629

PROGRAM SEVENTY-SIXTH ANNUAL MEETING

11:15

12:00

A. M.
9:30

10:00

10:20

“Cerebral Atrophy in Infants and Children”

Harold K. Faber, M.D., San Francisco

A. B., Harvard College,
1906; M.D., University of
Michigan, 1911. Professor
of Pediatrics, Stanford Uni-
versity School of Medicvne;
Pediatrician-in-Chief, Stan-
ford University Hospitals,
San Francisco. Member:
American Pediatric Society,
American Academy of Pedia-
trics, Society for Pediatric
Research, et cetera.

The causes of mental de-
ficiency, spastic diplegia and
convulsive disorders long ob-
scure, have been clarified for
a considerable percentage of
cases by consideration of the
Harold K. Faber effects of anoxia on the
brain and by studies of the
air encephalogram. Heredity is now found to play
a much smaller part than had been previously sup-
posed, and the same is true of intracranial hernor-
rhage at birth. It is, however, a mistake to believe
that all cases date from the time of birth.' Both
fetal and postnatal disorders are of etiological im-
portance. A series of cases is reviewed in which
the causative factors are discussed. Some preventive
suggestions are presented.

Business Meeting — Election of Officers

MSMS

SECTION ON DERMATOLOGY AND
SYPHILOLOGY

Chairman: Claud Behn, M.D., Detroit
Secretary: Frank Stiles, M.D., Lansing
Directors’ Room — Civic Auditorium

“Therapeutic Effects of Vitamin B Factors
in Dermatology”

Carroll S. Wright, M.D., Philadelphia

The various factors of Vitamin B are of more
than O'rdinary intrest to the dermatologist. Vitamin
Bi is now widely used to relieve the pain of herpes
zoster and there is some evidence that it may be

helpful in psoriasis. The spectacular improvement
in pellagrins following the administration of nicotinic
acid is now fully recognized. Riboflavin cures

cheilosis, erosions aiound the eyes, “sharkskin”
lesions of the skin over the nose and may be

helpful in fissuring around the ears. It also in-

creases the efficacy of nicotinic acid in certain
pellagrins (Spies). The filtrate factor (pantothenic
acid) is probably not concerned in pellagra. Interest
centers in its anti-gray hair action. Vitamin Be

(piyrodoxine hydrochloride), often called the “rat
anti-dermatitis factor” is known to have a definite
action in the treatment of pellagra . This study is
concerned chiefly with the treatment of various types
of dermatitis (or eczema) with Vitamin Be, including
studies of the urinary excretions of this Vitamin.

Discussion

“Diagnosis and Treatment of Vesicular and
Vesiculo-pustular Eruptions of the Hands
and Feet”

S. William Becker, M.D., Chicago

B. S., 1918, M.D., 1921,

U niversity of Michigan;
M.S., 1928, University of

Minnesota; Assistant Profes-
sor Dermatology, University
of Chicago, 1927-30, Associate
Professor since 1930. Mem-
ber A.M.A. and component
societies; American Academy
of Dermatology and Syphil-
olgy; American Dermatolog-
ical Association; and other
organizations ; Diplomate of
American Board of Derma-
tology and Syphilology. Auth-
or: “Commoner Diseases- of
the Skin,” 1935; “Ten Mil-
lion Americans Have It,”
1937; “Modern Dermatology
and Syphilology,” 1940 (with

S. William Becker Obermayer).

Critical study has shown that vesicular fungous
infection of the hands is almost unknown. Vesicular
eruptions of the feet (athletes’ foot) have been proven
to be caused by fungi in only five to 15 per cent of
children and only 30 per cent of adults. The heat
of summer increases the percentage of fungous in-
fection to SO.

Epidermal hypersensitivene.ss to fungous allergens
may result in vesicular lesions on the hands
(trichophytids), produced by allergens reaching the
palms from the feet through the blood stream. Other
vesicular and vesiculo-pu.stular eruptions of the hands
(bacterids, dyshidrosis on fungous basis) cannot be
proven to be allergic, since epiderman hypersensitive-
ness does not exist in patients with such disorders.

10:50 Discussion

11:10 “Five-Day Treatment of Early Syphilis”
Loren W. Shaffer, M.D., Detroit
11:40 Discussion
12:00 Election of Officers
P. M.

12:30 Luncheon at Pantlind Hotel

MSMS

SECTION ON RADIOLOGY, PATHOLOGY AND
ANESTHESIA

Chairman : Frank W. Hartman, M.D., Detroit
Secretaries : Clyde K. Hasley, M.D., Detroit,
Frank J. AIurphy, M.D., Detroit
Re<l Room — Civic Auditorium

PANEL DISCUSSION ON “SOME PHASES OF
THE CANCER PROBLEM”

9:30 A. M.

1. Diagnosis

(a) General

Henry J. VandenBerg, M.D., Grand Rapids
N. M. Allen, M.D., Detroit

(b) X-Ray

Bernard H. Nichols, M.D., Cleveland

M.D., Starling Medical
College, 1940; Practiced gen-
eral medicine and roentgen-
ology at Ravenna, Ohio,
from 1904 to 1917; com-
missioned in Medical Corps
of the U. S. Army and be-
came instructor of Roentgen-
ology at Cornell University,
New York City. Member
Base Hospital 55 as Chief
of Department of Roentgen-
ology in September 1918, di-
rected Department of Roent-
genology in France until
end of war. Returned to
U. S. A. and became Direc-
tor of Roentgenology in the
Bernard H. Nichols Embarkation Hospital, No. 3,
New York City. Discharged
from Army, September, 1920; Director of Depjortment
of Roentgenology in Cleveland Clinic from 1920 to
date. Pres -dent Radiological Society of North Amer-
ica in 1940. Co-author with Dr. William E. Lower
of text book “Roentgenographic Studies of t^

Urinary System ” has published about 100 scientific
articles.

Lawrence Reynolds, M.D., Detroit

(c) Pathology

Carl V. Weller, M.D., Ann Arbor
Donald C. Beaver, M.D., Detroit

2. Ti’eatment

(a) Surgical

Roy D. McClure, M.D., Detroit
Fred A. Coller, M.D., Ann Arbor

(b) Irradiation

Rollin H. Stevens, M.D., Detroit
Isadore Lampe, M.D., Ann Arbor

3. Registration and Follow-Up

Shields Warren, M.D., Boston
Fred J. Hodges, M.D., Ann Arbor
Traian Leucutia, M.D., Detroit
A. B. McGraw, M.D., Detroit

Election of Officers

630

Jour. M.S.M.S.

PROGRAM SEVENTY-SIXTH ANNUAL MEETING

FRIDAY AFTERNOON
September 19« 1941

Seventh General Assembly

Black and Silver Ballroom — Civic Auditorium

Henry R. Carstens, M.D., Presiding
L. Fernald Foster, M.D., and Leon De Vel, M.D.,
Secretaries

P. M.

1:30 “Focal Infection in the Nose and Throat —
Retrospect and Forecast”

D, E. Staunton Wishart, M.D., Toronto, Ontario

B.A., 1909, M. D., Uni-
versity of Toronto, 1915.

Three years’ service in the
field with the 10th (Irish)
Division. Mediterranean Ex-
peditionary Force — Sulva
Bay, Serbia, Struma Valley
and Palestine. Surgeon-in-
Chief, Department of Oto-
laryngology, Hospital for
Sick Children, Toronto, and
Senior Demonstrator, Depart-
ment of Otolaryngology, Uni-
versity of Toronto. Author
of: Section on Surgery of
the Ear, Lewis’ System of
Surgery: Relation of infec-
tion of the Ear and Infec-
D. E. S. Wishart tion of the Intestinal tract

in Infants, Results of five
years’ study — Routine Hearing Tests and many other
scientific articles.

2:00 “New Therapy of Common Skin Diseases”
Carroll S. Wright, M.D., Philadelphia

B.S., University of Michi-
gan, 1917; M.D., University
of Michigan, 1919. Instruc-
tor in Dermatology and
Syphilology University of
Michigan Medical School,
1920-1922 ; Associate Profes
sor of Dermatology and
Syphilology Graduate School
of Medicine, University of
Pennsylvania. Professor of
Dermatology and Syphilology
Temple University School of
Medicine. Consultant Der-
matologist to Philadelphia
Municipal Hospital; Widener
School for Crippled Chil-
dren; Shriner’s Hospital;
Carroll S. Wright Pennsylvania Institute for
Blind; Pennsylvania Institute
for the Dumb; Vineland Training School. Trustee
of Research Institute of Cutaneous Medicine. As-
sociate Editor of the "Medical World" and "The
Weekly Roster and Medical Digest.” Member of
American Dermatological Association, Society for In-
vestigative Dermatology, American Academy of Der-
matology, Philadelphia College of Physicians, Nu
Sigma Nu and Sigma Xi. Author of textbooks
"Treatment of Syphilis” with Dr. Jay F. Schamberg
and "Manual of Dermatology” and numerous con-
tributions to dermatological literature.

Since the turn of the century there has been
marked progress in the treatment of many of the
commonly seen skin diseases. Unsightly vascular nevi
with the exception of port-wine marks can be suc-
cessfully treated in one of several ways. The acne
of adolescence, at our time considered a necessary
evil to be suffered in silence until cured by nature,
is in most instances amenable to modern therapy with
a resultant lessening in badly scarred faces. The
fungus infections which may attack any part of the
human integumnet and its appendages can in most
cases be conquered. In the treatment of those skin
infections due to cocci, new drugs administered both
internally and externally have improved therapeutic
results. Psoriasis still remains a disease of unknown
etiology and must still be considered incurable, but
there is evidence of some progress as regards its
therapy. Skin cancer, unless woefully neglected, may

August, 1941

be regarded as curable with present day methods of
treatment. The situation with regard to the “cur-
ability” of skin diseases has changed since the day
25 or 30 years ago that a dermatologist gave as one
of his reasons for selecting this specialty that “pa-
tients with skin diseases never get well.” These
newer therapeutic procedures in the above named
dermatoses will be discussed.

2:30 INTERMISSION TO VIEW THE EXHIBITS

3:00 “Child Health in National Defense”

Borden S. Veeder, M.D., St. Louis, Missouri

3:30 “The Relationship of the Reticulo-En-
dothelial System to Cellular and Humoral
Immunity”

C. A. Doan, M.D., Columbus, Ohio

B.S., Hiram College; M.D.,
1923 Johns Hopkins Medical
School. R.H.O., Johns Hop-
kins Hospital, 1923; Assist-
ant Department of Anatomy,
Johns Hopkins, 1924; Assist-
ant Department of Medicine
Harvard Medical School; As-
sistant Physician, Boston City
Hospital; Assistant Thorn-
dike Memorial Laboratory ;
Associate in Medical Re-
search, Rockefeller Institute,
1925-30. Fellow and mem-
ber of numerous scientific
and medical organisations.
President Ohio Public Health
Association, 1939 to date;

C. A. Doan Director-at-large National

Tuberculosis Association.
Author of mfire than 100 scientific articles and books
on medical subjects, particularly hematology and
tuberculosis.

The phagocytic cells which comprise the Reticulo-
Endothelial System of the body have long been known
to function physiologically as conservators of essential
materials from worn out or senile blood cells. More
recently, excessive pathologic sequestration of red
cells, granulocytes or blood platelets in the par-
enchyma of the spleen, with symptom-producing de-
struction of these essential elements by hyperplastic
splenic macrophages, has resulted in recognition of
several clinical syndromes, each one of which has
been effectively controlled by successful splenectomy.

Still more recently studies with “marked” dye
antigens have definitely established these phagocytic
elements as the most probable source of circulating
specific anti-bodies. This latter evidence places on
a sounder basis, the approach to the problems of
humoral immunity, and demonstrates the extremely
close association with cellular immunity.

4:00 “The Ulcer Problem and The Surgeon”

Owen H. Wangensteen, M.D., Minneapolis .

A.B., University of Min-
nesota, 1919; M.D., 1922;
Ph.D., (Surgery) , 1925; Pro-
fessor in Surgery since 1931,
Director of Department and
Surgeon-in-Chief since 1930.
Served in World War as a
private in Student Training
Corps. Member of many
scientific and medical organ-
isations.

The importance of acid in
the genesis of ulcer will be
emphasized. Experiments per-
formed in the Surgical Lab-
oratory, in which ulcer has
been produced in a variety
oif animals by stimulating the
Owen H. Wangensteen endogenous gastric secretory
mechanism, will be reviewed.
The choice of operative procedure in the surgical
management of ulcer, which will insure effective de-
pression of the gastric secretory mechanism, will be
discussed, and the criteria of an acceptable operation
defined. Technical and nutritional problems which
confront the surgeon, affording his patient maximal
assurances of safety, will be presented.

4:30 End of Seventh General Assembly
END OF CONVENTION

631

TECHNICAL EXHIBITS

TECHNICAL EXHIBITS

Abbott Liaboratories Booth No. C-3

North Chicago, Illinois

You are heartily invited to discuss the nevirer spe-
cialties with the Abbott-trained Professional Repre-
sentatives in attendance. The wide assortment of
products displayed in this exhibit merit your atten-
tion and study. Your questions are solicited. De-
scription of the items shown is prohibited by space,
so! COMB IN AND SEE US!

Ernst BischofI Company Booth No. E-19

Ivoryton, Connecticut

ACTIVIN, the first American produced shockless
foreign protein for nonspecific therapy. ANAYODIN
is an effective, non-toxic amebicide. It attacks the
amebas which have penetrated the tissues. DIA-
TUSSIN, the original drop-dose cough remedy with
a thirty-five year record of efficacy. LOBELIN-
Bischoff, a direct stimulant to the respiratory cen-
ter. The resuscitant indicated in all forms of re-
spiratory failure or depression. STYPTYSATE, a
vegetable hemostatic, with extremely high vitamin
K activity, indicated for the control of all seeping
hemorrhages.

The Baker Liaboratories Booth No. D-7

Cleveland, Ohio

Baker’s complete line of infant foods, indicating the
newer trends in modern infant feeding, will be on
display. Baker MODIFIED MILK, powder and liquid,
is a completely modified milk in which the composi-
tion of the essential food elements has been so
altered and adjusted as to closely approximate
breast milk. MELCOSB, a completely prepared liquid
milk is very economical. MELODBX, maltose and
dextrin, is made especially for modifying fresh or
evaporated milk.

Bard-Parker Company Booth No. C-2

Danbury, Connecticut

The following products will be exhibited at the
Bard-Parker Booth: rib-back surgical blades, long
knife handles for deep surgery, renewable edge
scissors, formaldehyde germicide, and instrument
containers for the rustproof disinfection of surgical
instruments, transfer forceps for the aseptic trans-
portation of instruments, hematological case for
obtaining bedside blood samples, ortholator for ob-
taining accurate dental radiographs.

Barry Allergy Laborntory, Inc. Booth No. B-15

Detroit, Michigan

A duplicate of the exhibit shown at the A.M.A. in
Cleveland will be brought to the Michigan State
Meeting in Grand Rapids. Services and products as
well as many research problems will be presented
in an interesting and unique manner. Both Mr.
Charles Fowler and Mr. Barry, President, will be
present to welcome all visitors.

Rudolph Beaver, Inc. Booth No. E-13

Waltham, Massachusetts

Newly developed all-bellied DeBakey
blades, which, held in any position,
always present a rounded cutting
edge. Also the recently developed
bent Ljungberg blades for deep and
special sur-
gery, such as
c h ol e cy stec-
tomy, hysterectomy, hip, spine, cleft
palate, semilunar cartilage. There
are also the conventional shape
blades. All blades fit every handle.

Becton, Dickinson & Co. Booth No. C-16

Rutherford, New Jersey

A full line of B-D Products including clinical ther-
mometers, hypodermic syringes and needles, Ace
bandages, Asepto syringes and a full line of their
diagnostic instruments including the new line of
low priced blood pressure instruments, will be on
display. Doctors will be particularly interested In
No. 5018 which comprises a portable type manometer
and triple change stethoscope in handy leather
pouch with slide fastener.

Bilhuber-Knoll Corporation Booth No. B-11

Orange, New Jersey

Your visits are welcomed. Mr.
Laurel Johnson will be glad to
give careful attention to ques-
tions and discussions on Dilau-
did, Metrazol, Phyllicin, Theocal-
cin, etc. Register for a copy of
the new “Note Book of Original
Medicinal Chemicals.” Colored
charts — muscular, skeletal, circu-
latory, and nervous systems may
be had upon request.

The Borden Company Booth No. F-I

New York City

Visit the Borden exhibit to see
infant foods of unsurpassed qual-
ity. Biolac, the distinctive new
liquid infant food, affords con-
venience, economy, and optimal
nutrition. Beta Lactos is na-
ture’s carbohydrate in an im-
proved, readily soluble form.
Dryco provides formula flexibil-
ity for every feeding problem.
Also Klim, Merrell-Soule prod-
ucts, and Irradiated Evaporated
Milk. Mr. H. H. Baker and Mr,
A. D. Farrell will be in charge
of the exhibit.

Burroughs Wellcome & Co. (USA) Inc.

New York City Booths No. B-4 and B-5

A representative group of fine chemicals and phar-
maceutical preparations, together with new and im-
portant therapeutic agents of special interest to the
medical profession, will be presented.

Cameron Surgical Specialty Company Booth No. B-8
Chicago, Illinois

See the new Cameron-Schindler Flexible Gastro-
scope, the Color-Flash Clinical Camera, the Pro-
jectoray, the Mirrorlite and latest developments in
electrically lighted diagnostic and operating instru-
ments for all parts of the body. You will also be
interested in our radio frequency knives and coagu-
lators.

S. H. Camp and Company Booth No. C-18

Jackson, Michigan

A life sized reproduction of the Camp Transparent
Woman will be displayed as the central theme of a
typical service department equipped to serve pa-
tients with the various supports prescribed by phy-
sicians. A complete line of merchandise for pre-
natal, postnatal orthopedic, visceroptosis, sacro-iliac,
hernia and other specific conditions will be shown.
Experts from the Camp staff will be in attendance
to answer questions.

Ciba Pharmaceutical Products Booth No. D-6

Summit, New Jersey

Physicians are cordially invited to visit the Ciba
Booth where they will find the well known line of
CIBA specialties on display.

Mr. Frank H. Pratt will be at the booth and will be
glad to discuss these products and supply interest-
ing new information regarding^ many of them.

Coca-Cola Company Booth No. A-7

Atlanta, Georgia

Coca-Cola will be served to the physicians with the
compliments of the Coca-Cola Company.

Cottrell-Clarke, Ine. Booth No. F-9

Detroit, Miehigan

Mostly in the east, are some half dozen specializing
printers engaged in supplying medical men with
records and stationery: still nowhere is there an
organization to compare with the personal attain-
ments of Michigan’s own COTTRELL-CLARKE, INC.
(locally and popularly known as “the physicians’
stationery folks”) in developing varied types and
sizes of folders and other ideas, all designed for
facilitating neater and better record keeping. By
all means see .Cottrell-Clarke’s exhibit this year.

The Cream of Wheat Corporation Booth No. D-16

Minneapolis, Minnesota

The 5-minute “CREAM OF WHEAT” will be on ex-
hibit. This improved cereal is completely cooked in
5 minutes and has been fortified with additional
vitamin Bi (wheat germ and thiamin), iron, cal-
cium, and phosphorus.

632

Jour. ^f.S.M.S.

TECHNICAL EXHIBITS

Cutter Liuboratories
Chicago, Illinois

Booth No. E-4

Cutter Laboratories will display their latest trans-
fusion equipment, including the Saftivalve Trans-
fusion Outfit and prepared human serum and plas-

ma.

Davis & Geck» Inc.
Brooklyn, New York

This One Thing We Do"

Booth No. A-4%

Davis & Geek, Inc. will
display its complete
line of sterile sutures
including . . . fine

gauge (0000 and 00000)
catgut ... a compre-
hensive group of su-
tures armed with swaged-on atraumatic needles
and designed for specific surgical procedures . . .
Dermalon skin and tension sutures (processed from
nylon) which, because of marked physical adva^
tages and economy, are rapidly replacing silkworm

gut and other nonabsorbable materials.

A further feature of this exhibit will be a motion
nicture theater in which a diversified program of
surgical films, in full color, will be presented daily.

R. B. Davis Sales Company Booth No. E-21

Hoboken, New Jersey

You are invited to enjoy a drink of de-
licious Cocomalt at Booth No. E-21.
Cocamalt is refreshing, nourishmg and
of the highest quality. It is fortified
with vitamins A Bi and D; calcium
and phosphorus to aid in the develop-
ment of strong bones and sound teeth;
iron for blood; protein for strength
and muscle; carbohydrate for energy.

DePuy Manufacturing Company Booth No. E-16

Warsaw, Indiana

You are invited to visit our exhibit where many
new fracture appliances and bone instruments will
be on display. Mr. Charles F. Klingel will be in
charge and will be glad to answer any of your
questions.

Detroit Creamery Company Booth No. F-3

Detroit, Michigan

Sealtest stands for quality milk, cream and ice
cream. The red and white tradename is an assur-
ance to the consumer of pure, wholesome dairy
products produced in modern, sanitary plants op-
erating under strict laboratory control.

Detroit X-Ray Sales Co. Booth No. A-4

Detroit, Michigan

The Detroit X-Ray Sales Company again takes
pleasure in presenting important advances in shock-
proof x-ray equipment, designed in the “Mattern
manner.”

We feel that a visit to our booth will interest those
contemplating the purchase of x-ray equipment.
A cordial welcome is extended. Messrs. Hanks,
McAlpine and Robinson, also Mr. R, J. Carseth, the
Mattern factory representative, will be in attend-
ance.

Dictaphone Corporation
Detroit, Michigan

Booth No. B-13

You are cordially invited
to inspect the new Dicta-
phone models and to learn
how this modern dictating
machine is serving physi-
cians throughout the coun-
try. Make the Dictaphone
Booth your headquarters.
The Dictaphone displays
will be in charge of H. E.
Trapp, Grand Rapids Man-
ager, assisted by members
of his staff.

The Dietene Company Booth No. B-7

Minneapolis, Minnesota

The Dietene Company cordially invites all members
of the Michigan State Medical Society and their
guests to visit our booth.

Our representatives will be looking forward to the
opportunity of presenting our group of special pur-
pose foods.

August, 1941

Doho Chemical Corporation Booth No. E-S

New York City

The Auralgan Exhibit consists of a model of the
human auricle four feet high together with a series
of twenty-four three dimensional ear drums, mod-
eled under the supervision of outstanding otologists.
Each of these drums depicts a different pathologic
condition based upon actual case observation and
prepared, in so far as possible, with strict scientific
accuracy so as to be highly instructive and inter-
esting to all physicians.

Duke liSboratories, Inc. Booth No. C-4

Stamford, Connecticut

The Duke Laboratories, Inc., will demonstrate the
original, American-made, stretchable, adhesive sur-
faced bandage, Elastoplast, which is used whenever
compression and support are required. Samples of
Mediplast and Elastoplast Occlusive dressing, now
being so widely used in plants on Defense work,
will be available. Ask for samples of the prescrib-
er’s cosmetics — Nivea and Basis Soap — too.

Booth No. E-5

THE E D I-
PHONE COM-
PANY extends
a cordial invi-
tation to all
physicians to
visit the dis-
play of EDI-
PHONE equip-
ment. See the
new Miracle
Model Edison
Voice Writ-
er, also new
Streamline
Cabinet de-
signs, manu-
factured by
Edison, who invented and perfected sound record-
ing. We welcome opportunity to demonstrate and
discuss its application in the medical profession.

H. G. Fischer & Co. Booth No. B-lft

Chicago, lilinois

To every visitor at the Michigan State Medical So-
ciety we give this special invitation: Look under

the hood of the new FISCHER models of apparatus
shown! FISCHER shockproof x-ray apparatus, short
wave units, ultra-violet and other generators are
built to stand the very hardest day-by-day usage.
Demand to be shown the real under-the-hood facts
about FISCHER Models.

C. B. Fiect Company Booth No. E-14

Lynchburg, Virginia

Phosphe-Soda (Fleet) is a highly concentrated and
purified, aqueous solution of sodium phosphates. It
is nontoxic, rapid but mild in action without irri-
tation of the gastric or intestinal mucosa. It is
indicated for hepatic dysfunction and for its tho-
rough eliminating and cleansing action on the upper
and lower gut.

General Electric X-Ray Corp. Booth No. A-5

Detroit, Michigan

We cordially invite the physicians and their fam-
ilies who attend this meeting to make use of the
lounge facilities provided at our booth for their
comfort. We particularly look forward to a visit
from users of our equipment and a cordial invitation
is extended to all physicians who may have tech-
nical problems to discuss with our staff in attend-
ance.

Gerber Products Company Booth No. E-12

Fremont, Michigan

The complete
line of Ger-
b e r Baby
Foods will bo
on display.
There are two
precooked
dry cereals,
one a wheat,
the other an
oatmeal cere-
al. Of the
canned foods,

there are both strained and Junior or chopped foods.
Booklets available for distribution to mothers or
patients on special diets as well as professional lit-
erature will be sent to registrants, for examination.

Gerber’s

Strained

Oatmeal

Q

The Ediphone Company
Grand Rapids, Michigan

635

TECHNICAL EXHIBITS

Hack Shoe Company Booth No. A-2

Detroit, Michigan

Twenty-five years of evolution in health shoe con-
struction will be exemplified in the Hack Shoe Com-
pany exhibit.

This pioneer prescription shoe organization will also
display a series of roentgenographs demonstrating
how the foot bones lie in correctly and incorrectly
fitting shoes.

HACK-O-PEDIC clubfoot and surgical shoes and
TRI-BANLANCE shoes for men, women and chil-
dren complete the exhibit.

Hanovia Chemical & Mfg. Company Booth No. C-17
Newark, New Jersey

The very latest in ultra-violet equipment will be
demonstrated, including the outstanding uses of
ultra-violet radiation in the fields of science, medi-
cine and public health. Don’t fail to see our new
line of self-lighting ultra-violet high-pressure mer-
cury arc lamps. Short and ultra short wave appara-
tus, Sollux Radiant Heat Lamps and our latest de-
velopment, quartz ultra-violet lamps for air sanita-
tion.

J. F. Hartz Company Booths No. E-6 and E-7

Detroit, Michigan

All physicians are invited to visit the booth of the
J. P. Hartz Company — the progressive medical sup-
ply firm of Detroit who are nationally known.

An interesting display of instruments, equipment,
and pharmaceuticals may be seen.

This firm has recently added another floor to care
for the expanding business of its manufactured
pharmaceuticals which are made under strict labora-
tory control, and In compliance with the regulations
of the Federal Food and Drug Department.

H. J. Heinz Company Booth No. E-18

Pittsburgh, Pennsylvania

The makers of Heinz Strained and Junior Foods ap-
preciate the confidence which the members of the
Michigan State Medical Society have expressed in
their recommendation of these foods for infant feed-
ing and special diets. F. B. Heard and H. A. Elen-
baas are at your service and will welcome members
and friends at the exhibit.

Holland-Rantos Company, Inc. Booth No. F-11

New York City

The latest developments in the field of medically
prescribed contraceptives will be featured at the
booth of the Holland-Rantos Company. Rantex
masks and Rantex caps for operating room will be
of unusual interest to surgeons who are looking
for something comfortable yet efficient in this line.

The G. A. Ingram Co. Booths No. D-21 and D-22

Detroit, Michigan

The G. A. Ingram Company extends an invitation
, to all visitors at the Michigan State Medical Con-
vention to make their booth their headquarters and,
especially, to investigate their new line of diagnos-
tic instruments and their complete line of genuine
Swedish stainless steel instruments. They will also
show the latest in electrical equipment.

Jones Metabolism Equipment Company Booth No. D-5
Chicago, Illinois

Interview our representative, William Niedelson,
about the development of the first waterless basal
through 20 years by the addition of many scientific
devices to assure accuracy, operative simplicity and
guarantee the purchaser a lifetime of use without
repair expense.

“The ‘.lunket’ Folks” Booth No. B-3

Chr. Hansen’s Liaboratory
Jiittle Falls, New York

“THE ‘JUNKET’ FOLKS’’ will serve rennet-custards
made with either “Junket’’ Rennet Powder or “Jun-
ket” Rennet Tablets. There is also a display of
“Junket” Brand Food Products. Enlarged photo-
graphs show how the rennet enzyme in rennet-
custards transforms milk into softer, finer curds.
Rennet-custards are widely recommended for in-
fants, children, convalescents, postoperative cases
and as a delicious, healthful dessert for the whole
family. Fully informed attendants on duty.

Kalak Water Company Booth No. E-17

New York City

Visit the KALAK WATER booth and ask the rep-
resentative how KALAK WATER may be employed
to minimize the discomforts that so frequently fol-
low the administration of the Sulfonamides. Ask

the representative to serve you with a glass of
KALAK WATER and learn for yourself how deli-
cious and refreshing KALAK WATER really is
when it is properly served.

Lea & Febiger Booth No. D-14

Philadelphia, Pennsylvania

Lea & Febiger will exhibit Portis’ Digestive Dis-
eases, Kraines’ Psychoses, Ballenger’s Manual,
Rowe’s Elimination Diets, Lewin’s The Foot and
Ankle, Rony’s Obesity and Leanness and new edi-
tions of Holmes and Ruggles’ Roentgenology, Jos-
lin’s Diabetes and Manual, Comroe’s Arthritis,
Bridges’ Dietetics, Spaeth’s Ophthalmology and
Kessler’s Accidental Injuries.

Lederle Laboratories Booth No. E-22

New York City

You are cordially invited to visit the Lederle Ex-
hibit which will feature colored slides on the re-
fining of Antitoxins. These slides were taken from
a new motion picture film on this subject.

They will exhibit the many specialties for which
they are noted and the latest releases in Sulfona-
mide drugs. Literature on the various Sulfonamides
will be available.

Libby, McNeill «fe Libby Booth No. B-17

Chicago, Illinois

You are cordially invited to visit Libby, McNeill &
Libby’s exhibit where attendants will point out the
merits of Homogenized Baby Foods, Chopped Foods
and Evaporated Milk. Libby’s special . .ethou of
Homogenization makes Libby’s Baby Foods extra
smooth, extra easy to digest.

liiebel-Flarsheim Company Booth No. C-7

Cincinnati, Ohio

Liebel-Flarsheim Company will ex-
hibit the well-known L-F Short
Wave Generators as well as the
famous Bovie Electro-Surgical Units
and other new and interesting elec-
tro-medical apparatus.

A cordial invitation is extended to
visit The Liebel-Flarsheim booth to inspect this
outstanding equipment and have it demonstrated to
you.

Eli Lilly and Company Booth No. C-1

Indianapolis, Indiana

Eli Lilly and Company will demonstrate the germi-
cidal efficacy of “Merthiolate” (Sodium Ethyl Mer-
curi Thiosalicylate, Lilly) and the compatibility of
the antiseptic with body cells and fluids. Other
new and useful products will be featured.

J. B. Lippincott Company Booth No. E-11

Philadelphia, Pennsylvania

New Lippincott books of interest to every physician
are Grollman’s “Essentials of Endocrinology,” To-
bias’ “Essentials of Dermatology,” Haden and
Thomas’ “Allergy in Clinical Practice” and You-
mans’ “Nutritional Deficiencies.” Leaman’s “Man-
agement of the Cardiac Patient,” today’s sales lead-
er, will be displayed, as will Thorek’s three-volume
“Modern Surgical Technic.”

The McKesson Appliance Company Booth No. D-20
Toledo, Ohio

The McKesson Appliance Co. will exhibit a complete
line of scientific equipment involving the uses of
anesthetic gases and oxygen therapy. Both water-
less and water spirometer type basal metabolism
units will be shown. Practical demonstrations will
be made on the new direct reading electrocardio-
graph.

M & R Dietetic Laboratories, Inc. Booth :^o. C-11
Columbus, Ohio

Similac, a completely modified milk especially pre-
pared for infants deprived either partially or en-
tirely of breast milk, will be featured. Mr. David
O. Cox and Mr. L. A. MacDonald w'ill appreciate the
opportunity to discuss the merits of Similac and its
suggested application for both the normal and
special feeding cases.

Mead Johnson & Company Booths No. C-21 and C-22
Evansvilie, Indiana

“Servamus Fidem” means We Are Keeping the
Faith. Almost every physician thinks of Mead
Johnson & Company as the maker of Dextri-Mal-

JouR. M.S.M.S.

634

TECHNICAL EXHIBITS

tose, Pablum, Oleum Percomorphum and other in-
fant diet materials. But not all physicians are
aware of the many helpful services this progressive
company offers physicians. A visit to Booths C-21
and C-22 will be time well spent.

Medical Arts Surgical Supply Company

Grand Rapids, Michigan Booths No. C-5, C-6 and B-14

The Medical Arts Surgical Supply Company of the
best city will show the exclusive line of Liebel Flar-
sheim short wave generators, the latest items in
the beautiful Ritter ear, nose and throat equipment,
and a complete suite of the Hamilton Nu Tone furni-
ture along with the latest in autoclave and steril-
ized units. An invitation is extended to all doctors
to call at these booths.

Medical Case History Bureau Booth No. D-9

New York City

Simplifying the Doctor’s History Record and Book-
keeping System with the INFO-DEX RECORD CON-
TROL SYSTEM.

Maintenance of accurate, informative data on both
history and financial records is essential in the
modern doctor’s practice. The INFO-DEX Record
Control System helps to keep a constant finger
on the physical and financial pulse of the patient.
This system correlates information almost auto-
matically for instant reference and research work.
Its method of cross-indexing interesting cases ac-
cording to the disease is unique and exclusive.

The Medical Protective Company Booth No. D-8

Fort Wayne, Indiana

The Medical Protective Company invites you to visit
its booth. Medical Protective Service is an institu-
tion of the Medical profession whose legal liability
problems we have concentrated upon for 42 years.
Bring your professional liability questions and
problems to us.

Mellin’s Food Company Booth No. E-15

Boston, Massachusetts

Physicians are cordially invited to call and to place
before our repesentatives all questions regarding
the composition of Mellin’s Food and its usefulness
in infant and adult feeding. It is suggested that
constipation in infancy and the preparation of nour-
ishment for adult patients who are far below nor-
mal as a result of prolonged illness or faulty diet
are particularly interesting topics for discussion.

The Mennen Company Booth No. A-1

Newark, New Jersey

The Mennen Company will exhibit
their two baby products — ^Antiseptic
Oil and Antiseptic Borated Powder.
The Antiseptic Oil is now being
used routinely by more than 90 per
cent of the hospitals that are im-
portant in maternity work. Be sure
to register at the Mennen exhibit
and receive your kit containing
demonstration sizes of their shav-
ing and after-shave products; also,
for the lucky number prize drawing
to be held at the close of the Con-
vention for DeDuxe Fitted Leather
Toilet Kits.

The Wm. S. Merrell Company Booth No. B-2

Cincinnati Ohio

The Merrell exhibit will feature Oravax, the oral ca-
tarrhal vaccine in enteric coated tablets for protec-
tion against the common cold; as well as other new
prescription specialties of timely interest. Merrell
representatives will be at the booth ready to show
these products and answer any question.

Michigan Medical Service Booth No. A-6

Michigan Hospital Service
Detroit, Michigan

Complete information about the Medical Service and
Surgical Benefit Plans of Michigan Medical Service
will be available in this featured exhibit of the
results of operation of the doctors’ prepaid group
medical service program.

There will also be an interesting display of the
working of the companion hospital service plan of
Michigan Hospital Service.

The C. V. Moshy Company Booth No. D-3

St. liOnis, Missouri

Physicians and surgeons interested in the new
developments in medicine and surgery are cordially
invited to inspect the new publications which will

August, 1941

be on display at the Mosby Booth. Outstanding
new volumes on surgery, dermatology, pediatrics,
gynecology, heart diseases, X-Ray, and practice of
medicine will be shown.

National Live Stock and Meat Board Booth No. B-12
Chicago, Illinois

The exhibit of the National Live Stock and Meat
Board will portray Meat as a source of the essen-
tial food elements, protein, fats, carbohydrates, cal-
cium, phosphorus, iron, copper and six vitamins
with special emphasis on the factors of the vita-
min B complex.

Nestle’s Milk Products, Inc. Booth No. D-19

New York City

The Nestle’s Milk Products,
Inc., exhibit will feature Lac-
llfMj togen which has given suc-
cessful results in infant feed-
ing for more than 15 years.

Parke, Davis & Company

Deroit, Michigan Booths Nos. C-12, C-13 and C-14

Featured in the Parke-Davis exhibit will be the
sex hormones, theelin and 'theelol; antisyphilitic
agents, such as mapharsen and Thio-Bismol; pos-
terior lobe preparations, including pituitrin, pitocin
and pitressin; and various adrenalin chloride prep-
arations.

Pelton & Crane Company Booth No. D-4

Detroit, Michigan

The Pelton & Crane Company will exhibit its com-
plete line of office sterilizers, autoclaves and operat-
ing lights: also, fountain cuspidors and other spe-
cialty items. The exhibit will be in charge of Mr.
C. K. Vaughan, who looks forward to the pleasure
of renewing old acquaintances.

Pet Milk Sales Corporation Booths Nos. C-9 and C-10
St. Louis, Missouri

An actual working model of a milk
condensing plant in miniature will be
exhibited by the Pet Milk Company.
This exhibit offers an opportunity to
obtain informajtion about the produc-
tion of Irradiated Pet Milk and its uses
in infant feeding and general dietary
practice. Miniature Pet Milk cans will
be given to each physician who visits
the Pet Milk Booth.

Petrolagar Laboratories, Inc. Booth No. D-2

Chicago, Illinois

Petrolagar Laboratories, Inc. offer, in addition to
samples of the Five Types of Petrolagar, an inter-
esting selection of descriptive literature and an-
atomical charts. Ask the Petrolagar representa-
tives to show you the HABIT TIME booklet. It is
a welcome aid for teaching bowel regularity to your
patients.

Philip Morris & Company Booth No. E-I

New York City

Philip Morris & Company will demonstrate the
method by which it was found that Philip Morris
cigarettes, in which diethylene glycol is used as the
hygroscopic agent, are less irritating than other
cigarettes. Their representative will be happy to
discuss researches on this subject, and problems
on the physiological effects of smoking.

Picker X-Ray Corporation Booth No. B-10

New York City

Visitors to the Picker X-Ray Corporation’s booth
will have an opportunity of seeing the well-known
Picker-Waite "Century.” This diagnostic unit pro-
vides for radiography and fluoroscopy in all positions
from the vertical to the Trendelenburg — either hand
or motor operated. Also on display will be a fine
example of a combination portable and mobile
.«hockproof x-ray unit. This apparatus is suitable
for general office use or portable work in the pa-

635

TECHNICAL EXHIBITS

tient’s home. A number of newly developed x-ray
accessories and diagnostic opaque chemicals will
be exhibited.

Professional Management Booth No. F-2

Battle Creek, Michigan

Bring your professional and business problems for
Free Consultation Service with any of the Profes-
sional Management staff. Henry C. Black and Alli-
son E. Skaggs, Battle Creek; Wendell A. Persons,
Saginaw; Willis B. Mallory, Detroit; and Morris C.
Flanders, Grand Rapids, will all be available to
members of the Michigan State Medical Society.

Riedel-de Haen, Inc. Booth No. B-6

New York City

The Riedel-de Haen exhibit will feature two chem-
ically pure bile acids: Decholin, the true choleretic,

and Degalol, the fat emulsifier. Physicians are in-
vited to register for abstracts of clinical reports
on these products. Attending representatives will
appreciate the opportunity to discuss the latest
developments in the therapeutic application of
chemically pure bile acids.

S.M.A. Corporation Booth No. D-1

Chicago, Illinois

Among the technical exhibits at the convention this
year is an interesting new display, which represents
the selection of infant feeding and vitamin prod-
ucts of the S.M.A. Corporation. Physicians who
visit this exhibit may obtain complete information,
as well as samples, of S-M-A Powder and the spe-
cial milk preparations — Protein S-M-A (Acidulated),
Alerdex and Hypo-Allergic Milk.

.'Sandoz Chemical Works, Inc. Booth No. D-15

New York City

This exhibit will stress Council-accepted products:
Gynergen (ergotamlne tartrate) for migraine and
uterine hemostatis; Digilanld, the crystallized initial
glycosides of Digitalis lanata, standardized gravi-
metrically and biologically; Scillaren and Scillaren-B,
pure cardiodiuretic squill ' principles, and Dandoptal,
an effective hypnotic. Also the original gluconate
preparations of calcium (Calglucon) for oral and
parenteral therapy.

W. B. Saunders Company Booth No. B-1

jPhiladelphla, Pennsylvania

Of particular interest are such new books as Ladd
& Gross’ “Abdominal Surgery in Infancy and Child-
hood.” Kilmer & Tuft’s "Clinical Immunology, Bio-
therapy and Chemotherapy,” Steinbrocker’s “Ar-
thritis,” Johnstone’s “Occupational Diseases,” Gray-
biel & White’s “Electrocardiography in Practice,”
Krusen’s “Physical Medicine,” Novak’s “Obstetrical
and Gynecological Pathology,” Walters & Snell’s
“The Gallbladder and Its Diseases,” the 1941 Mayo
■Clinic Volume, Griffith & Mitchell’s “Pediatrics,” and
a number of other important new books and new
editions.

•Schering Corporation Booth No. E-3

Bloomfield, New Jersey

The Schering exhibit includes real and striking re-
cent advances such as SULAMYD, highly effective
sulfacetimide of considerably lower toxicity; orally
active sex hormones, ORETON-M, PROGYNON-DH
and PRANONE tablets; efficient BARAVIT for bulk
laxative therapy; and the new physiological antacid,
LUDOZAN tablets, forming a true protective gel in
your patient’s stomach.

Scientific Sugars Company Booth No. C-15

Columbus, Indiana

Scientific Sugars Company will display Cartose,
Hidex, and the Kinney line of nutritional products.
Physicians are cordially invited to stop. Well in-
formed representatives will be in attendance.

Sharp & Dohme Booth No. D-12

Philadelphia, Pennsylvania

Sharp & Dohme will show their new modern dis-
play this year, featuring “Delvinal” Sodium, “Lyo-
vac” Normal Human Plasma, “Lyovac” Bee Venom
Solution, and other' “Lyovac” biologicals. There will
also be on display a group of new biological and
pharmaceutical specialties prepared by this house,
such as “Propadrine” Hydrochloride products, “Ra-
bellon,” “Padrophyll,” “Riona,” “Depropanex” and
“Ribothiron.” Capable well-informed representa-
tives will be on hand to welcome all visitors and
furnish information on Sharp & Dohme products.

Smith, Kline & French liUboratories Booth No. E-10

Philadelphia, Pennsylvania

This year. Smith, Kline & French Laboratories be-
gins its second century of service to the medical
profession. The members of the Michigan State
Medical Society are cordially invited to visit this
exhibit and discuss the products displayed. These
will include benzedrine inhaler, benzedrine sulfate
tablets, benzedrine solution, and pentnucleotide.

Frederick Stearns & Company

Detroit, Michigan Booths No. D-10 and D-11

Doctors are cordially invited to visit our attractive
convention booths, to view and discuss outstanding
contributions to medical science developed in the
Scientific Laboratories of Frederick Stearns &
Company.

Our professional representatives will be pleased
to supply all possible information on the use of
such outstanding products as Neo-Synephrin Hydro-
chloride for intranasal use, Mucilose for bulk and
mbrication, Ferrous Gluconate, Potassium Gluconate
Gastric Mucin, Susto, Trimax, Appella Apple Pow-
der, Nebulator with Nebulin A, and our complete
line of vitamin products, together with liver ex-
tract U.S.P., oral and subcutaneous for the treat-
ment of pernicious anemia as well as other prod-
ucts will be readily available.

E. R. Squibb & Sons Booth No. D-13

New York City

A nuniber of new and interesting chemotherapeutic
specialties, vitamin, glandular and biological prod-
ucts will be featured in the Squibb Exhibit. Well
informed Squibb Representatives will be on hand to
welcome you and to furnish any information de-
sired on the products displayed.

tl. S. Standard Products Company Booth No. C-20
Woodworth, Wisconsin

MAGSORBAL will be on display by the U. S. Stand-
ard Pri^ucts Company at the State Medical Meet-
ing in Grand Rapids. Have our representative tell
you about the merits of this product. Other items
of great interest will be on display.

Wall Chemicals Corporation Booth No. E-3

Detroit, Michigan

Wall Chemicals Corporation, a division of the Liquid
Carbonic Corporation, will have on display a quan-
tity of compressed gas anesthetics and resuscitants.
There will also be a complete line of oxygen ther-
apy equipment including the “Walco” oxygen hu-
midifier, for the nasal administration of oxygen,
and the “Walco” oxygen face mask.

Westinghouse X-Ray Co., Inc. Booth No. C-19

Detroit, Michigan

The Westinghouse X-Ray Division will display the
most recent development of compact x-ray equip-
ment. Considering the size, there is greater power
than heretofore. The recently publicized bacteri-
cidal “Sterilamp” and “Thin Window Lamp” will be
available for examination. The “Scialytic,” standard
of surgical lighting will be shown in the latest
models.

White Laboratories, Inc. Booth No. E-9

Newai'k, New Jersey

"White Laboratories, Inc., will present White’s Cod
Liver Oil Concentrate Liquid, Tablet and Capsule
(and White’s Thiamin Chloride Tablet) — all Council-
accepted.

The practical advantages provided by cod liver oil
concentrate as an economical and convenient meas-
ure of vitamins A and B prophylaxis and therapy
will be discussed. Pertinent information concerning
our newer knowledge of the vitamins and vitamin
deficiency states will be offered for consideration.

Winthrop Chemical Company, Inc. Booth No. C-8

New York City

A cordial invitation is extended to every member
of the Michigan State Medical Society to visit Booth
No. C-8 where representatives will gladly discuss
the latest preparations made available by this firm.
You will receive valuable booklets dealing with
anesthetics, analgesics, antirachitics, antispasmodics,
antisyphilitics, diagnostics, diuretics, hypnotics,
sedatives and vasodilators.

John Wyeth & Brother, Inc. Booth No. A-3

Philadelphia, Pennsylvania

You are cordially invited to visit the John Wyeth
and Brother exhibit where the following pharma-
ceutical specialties will be on display:

Jour. M.S.M.S.

-636

COMMITTEE REPORTS

Amphojel, Wyeth’s Alumina Gel, for the control of
hyperacidity and peptic ulcer. Wyeth s Hydrated
Alumina Tablets, for the convenient control of
hyperacidity. Hagromagma, Wyeth’s magma of
alumina and kaolin, for the control of diarrh^.
B-Plex, Wyeth’s Vitamin B Complex Elixir. A-B-
M-C Ointment, the rubefacient, counter-irritant, for
the relief of arthritic pain. Bepron, Wyeth’s Beef
Liiver with iron. Bewon Elixir, Wyeth’s palatable
appetite stimulant.

Zimmer Manufacturing Company Booth IVo. E-20

Warsaw, Indiana

A complete line of fracture equipment will be
on display. Tour factory representative, Mr. Fisher,

I will be pleased to see you, .and demonstrate any
item. Of special interest — a sterilizable bone plate
and screw container which should be seen, the new
S-M-O Bone Plates and Screws, a screw driver
that is different, and the Luck Bone Saw complete
with all attachments.

-MSMS-

HOUSB OP DELEGATES, 1941
REFERENCE COMMITTEES

Credentials Committee

Luther W. Day, M.D., Chairman
C. W. Oakes, M.D.

V. Vandeventer, M.D.
P. W. Kniskern, M.D.

On Oflloers’ Reports — ^Parlor B, Pantlind Hotel

H. P. Dibble, M.D., Chairman
G. H. Yeo, M.D.

Carl P. Snapp, M.D.

C. A. Dickinson, M.D.

M. G. Becker, M.D.

On Reports of the Council — ^Room 122,
Pantlind Hotel

E. D. Spalding, M.D., Chairman

Don V. Hargrave, M.D.
Frank E. Reeder, M.D.
E. N. D’ Alcorn, M.D.

A. T. Hafford, M.D.
Wm. D. Barrett, M.D.

On Reports of Standing Committees — ^Room 124,
Pantlind Hotel

I Dean W. Myers, M.D., Chairman

j Harvey Hansen, M.D.

Douglas Donald, M.D.

! J. M. Robb, M.D.

' Henry Cook, M.D.

i Don W. Thorup, M.D.

' Merle Wood, M.D.

i A. E. Stickley, M.D.

C. E. Toshach, M.D.

i On Reports of Special Committees — ^Room 126,
i Pantlind Hotel

Geo. H. Southwick, M.D., Chairman
' Geo. J. Curry, M.D.

Irving Greene, M.D.

C. T. Ekelund, M.D.

Ellery Oakes, M.D.

i C. P. De Vries, M.D.

On Amendments to Constitution and By-Laws —
Room 127, Pantlind Hotel

i E. W. Foss, M.D., Chairman

I A. E. Catherwood, M.D.

I C. L. Hess, M.D.

I W. R. Young, M.D. ,

I W. P. Strong, M.D

On Resolutions — Room 128, Pantlind Hotel

W. B. Cooksey, M.D., Chairman
i L. G. Christian, M.D.

S. L. Loupee, M.D.

W. H. Alexander, M.D.

A. V. Wenger, M.D.

Reference Committee Reports are to be submitted
to the House of Delegates in triplicate.

I August, 1941

■ COMMITTEE REPORTS ■

SUMMARY OF PROCEEDINGS OF
HOUSE OF DELEGATES, 1940

The seventy-fifth annual meeting of the House of
Delegates of the Michigan State Medical Society was
held at Detroit, September 24, 1940.

The House of Delegates :

1. Accepted and adopted with thanks the reports of
the President (872*), President-Elect (872) ; The
Council (872), Delegates to the AMA (872), Legis-

(872), Public Relations Committee

(873) , Representatives to Joint Committee on Health
Education (873), Cancer Committee (873), Post-
gradua.te Medical Education Committee (873), Ethics

Preventive Medicine Committee
Degenerative Diseases Committee

(874) , Industrial Health Committee (874), Syphilis
Control Committee (873), Tuberculosis Control (873)
Mental Hygiene Committee (874), Child Welfare (in-
cluding Iodized Salt) Committee (874), Maternal
Health Committee (873), Committee on Distribution
of Medical Care (884), Radio Committee (876),
Scientific Work Committee (876), Conference Com-
mittee on Prelicensure Medical Education (877)
Medical -Legal Committee (873), Advisory Committee
on Nurses Training Schools (876), and Membership
Committee (876).

2 Referred to the 1941 session of the House of
Delegates the following proposed amendments to the
Constitution and By-Laws of the M.S.M.S. :

(a) Constitution: Article IV, Section 3, re making
past-presidents ex-officio members of House of Dele-
gates, without power to vote, (877).

IX. Section 4, re finances
(877). Reference Committee recommended that this
propotsed amendment be rejected.

(c) Constitution: New Article XII and renumber

present Article XII to No. XHI, re definitions of
“sessions and meetings” (880).

(d) By-laws: Chapter 10, Section 1, re Amendments
(880) .

3. Elected the following to Emeritus Membership
(881): Drs. W. J. O’Reilly, Saginaw; Donald K.
MacQueen, Laurium; George Bates, Kingston; Leslie
A. Howe, Breckenridge; James H. Sanderson, Detroit;
and Frank P. Bohn, Newberry.

To Retired Membership; Drs. C. S. Sackett, Char-
lotte ; E. M. Cooper, Rockwood ; Mark S. Knapp,
Lake Fenton ; C. S. Sutherland, Clarkston ; James W.
Wallace, Saline; James F. Breakey, Ann Arbor; W. E.
Wilson, and T. W. Hammond, Grand Rapids.

To Associate Membership: Mr. John R. Mannix,
Detroit.

To Honorary Membership (Posthumous) : Stuart

Pritchard, M.D.

4. Presented scroll to Philip A. Riley, M.D., for his
services to the Michigan medical profession (863).

5 Amended Constitution;

(a) Article HI, Sections 1, 2, 3, 4, and 8; Added
two new sections, all with regard to membership
classification (878-879) .

(b) Article IV, Section 3, re membership of Society
officers in House of Delegates (878).

(c) Article HI, Sections 1 and 2, re Junior Members.

6. Approved Resolutions concerning;

(a) Public Relations (872)

(b) Genito-Infectious Disease Program (883)

(c) Change in name of O.M.C.O.R.O. Society to
“Medical Society of North Central Counities” (882)

(d) Beaiunont Bridge (882)

(e) New Gavel to Spes^er (881)

7. Disposed of other Resolutions as follows :

(a) Proposed Amendment to Afflicted Children’s Act

637

COMMITTEE REPORTS

was referred to the M.S.M.S. Legislative Committee.

(b) Maternal Health Resolution was not adopted.

(c) General Practitioners in Hospitals Resolution
was referred to the M.S.M.S. Committee on Distribution
of Medical Care.

8. Referred to The Council the matter of the un-
satisfactory convention accomodations at the 1940
meeting.

9. Elected :

(a) C. E. Umphrey, M.D., Detroit, Councilor of 1st
District (887)

(b) Philip A. Riley, M.D., Jackson, Councilor of
2nd District (884)

(c) Wilfrid Haughey, M.D., Battle Creek, Counci-
lor of 3rd District (885)

(d) Otto O. Beck, M.D., Birmingham, Councilor of
15th District (885)

(e) A. S. Brunk, M.D., Detroit, Councilor of 16th
District (885)

(f) Henry A. Luce, M.D., Detroit, Delegate to
A.M.A. (885)

(g) T K. Gruber, M.D., Eloise, Delegate to A.M.A.
(885)

(h) Frank E. Reeder, M.D., Flint, Delegate to
A.M.A. (886)

(i) C. R. Keyport, M.D., Grayling, Delegate to
A.M.A. (886)

(j) Carl F. Snapp, M.D., Grand Rapids, Alternate
Delegate to A.M.A. (886)

(k) C. S. Gorsl'ne, M.D., Battle Creek, Alternate
Delegate to A.M.A. (886)

(l) R. H. Denham, M.D., Grand Rapids, Alternate
Delegate to A.M.A. (886)

(m) Henrv R. Carstens, M.D., Detroit, President-

Elect (886) ^ ^

(n) O. D. Stryker, M.D., Fremont, Speaker, House
of Delegates (886)

(o) James J. O’Meara, M.D., Jackson, Vice Speaker
House of Delegates (887)

10. Thanked Wayne County Medical Society, et al.,
for contributing to success of meeting. (887)

MSMS

PROPOSED AMENDMENTS TO CONSTITU-
TION AND BY-LAWS OF MICHIGAN STATE
MEDICAL SOCIETY

The following amendments were presented at the
1940 Convention and according to the Constitution were
referred to* the 1941 Session of the House of Delegates
for final consideration ;

Constitution

1. Amend Article IV, Section 3 to read as follows:
“The officers of this Society, Past Presidents, an,d
Members of The Council shall be ex-officio members of
the House of Delegates without power to vote.’’

Comment : This amendment adds the past presidents
of the Michigan State Medxal Society to the ex-
officio' members of the House of Delegates.

2. Amend Constitution, Article IX, Section 4, to read
as follows : “The Secretary shall collect all annual dues
and all monies owing to the Society, depositing them in
an approved depository and disbursed by him upon
order of The Council, or invested by him in United
States Government bonds with approval of The Coun-
cil.”

Comment: The Reference Committee, in 1940,

recommended that this proposed amendment re finances
be rejected.

3. Amend Article XII, Section 1 to read a's follows:
“The House of Delegates may amend any article of
this constitution by a two-thirds vote of the Delegates
seated at any annual session, provided that such amend-
ment shall have been presented in open meeting at the
prevxus annual session, and that it shall have been
published at least once during the year in the Journal
of the Society, or sent officially to each component

society at least two months before the meeting at which
final action is to be taken.”

Comment : This amendment changes the word

“present” to “seated.” See next amendment re “Sessions
and Meetings.”

4. Amend Constitution by adding a new article to be
known as Article XII :

“SESSIONS AND MEETINGS

“Section 1. A session shall mean all meetings at any
one call.

“Sedtion 2. A meeting shall mean each separate con-
vention at any one session.”

Comment : This new Article is for the purpose of
clarifying what is meant by the terms “sessions and
meetings.”

5. Amend the Constitution by renumbering old Arti-
cle XII to “XIII.”

By-Laws

6. Amend By-Laws, Chapter 10, Section 1, to read
as follows : “These By-Laws may be amended by a
majority vote of the delegates present, after the pro-
posed amendment is laid on the table for one meeting.
These By-Laws become effective immediately upon adop-
tion.”

Comment : This amendment consists of substituting
the word “meeting’’ for the word “session” to bring
the By-Laws in conformity with the Constitution upon
the adoption of above proposed amendments, thereto.

MSMS

ANNUAL REPORT OF THE COUNCIL,
M.S.M.S., 1940-41

Since the 1940 House of Delegates adjourned. The
Council has convened four times (up to September 16,
1941) and the Executive Committee ten times, a total
of fourteen meetings. As in past j'ears, all the business
of the Society, including matters studied and recom-
mendations madle by the twenty-two committees of the
M.S.M.S., were routinely referred to The Council or its
Executive Committee for consideration, approval, and
action.

Membership

Members in good standing as of July 31 and as of
December 31, for the years 1935 to 1941, inclusive, are
indicated in the following chart :

1941 1940 1939 1938 1937 1936 1935

July 31 4,403 4,401 4,255 3,958 3,757 3,457 3,410

December 31 4,527 4,425 4,205 3,963 3,725 3,653

The scientific and sociologic progress of the M.S.M.S.
is best indicated by the unusual increase in membership
made during the last six years.

Finances

The society closed its books for the last fiscal year
on December 24, 1940. An audit by Ernst & Ernst was
published in The Journal in February. Reference to
this report will disclose the sound financial condition of
the Society.

The 1941 budget was drawn by the Finance Com-
mittee of the Council at the annual meeting in January.
This was studied by the entire Council and after
thorough discussion was adopted. The policy behind the
budget was to place a ceiling on invested funds and to
return to the membership the largest service possible.

The plan of keeping invested funds in high grade
bonds is being continued. The listed price of these
securities are studied at the meetings of the Council
and its Executive Committee and occasional changes are
made when necessary. Since the close of the fiscal j-ear
funds in substantial amounts have been invested in
U. S. Government Bonds.

Comparison of expenditures to budgetary allotments
is made periodically by the Executive Committee of

Jour. M.S.M.S.

638

COMMITTEE REPORTS

The Council and the budget is followed rather strictly
unless altered circumstances demand changes. In
general, the expenses are being kept well within the
budget.

The Journal

i The Publication Committee believes a free copy of
j The Journal should be sent to each hospital in the
I state which has interns or resident physicians, this
\ to be done as an educational matter to promote interest
[ in Medical Society Memberships and the activities of
[ organized medicine.

; The Publication Committee believes that the Society
i should make some real investment in The Journal.
i It believes in the increased earnings of The Journal
but feels that it should also render an increased service
; by making more publication space available for original
! articles and by the publication of various society
activities. These provisions would increase the size and
usefulness of The Journal.

While keeping the cost of The Journal within the
previous budget further enhancements to the appearance
and value of The Journal have been made during the
f past year.

; The quality of the scientific papers has been uniformly
I good, and continuous effort is being made to keep them
i from being too verbose and to have them well illus-
; trated. Only papers which are of interest to the prac-
ticing physician are accepted. No papers are accepted
from non-members unless they have been delivered
before meetings held in this state. Abstracts of all
papers published are sent to the other state medical
journals in order to provide the widest possible dis-
semination of the products of our members. These
have been well received.

No opportunity has been spared to make The Journal
a more beautiful and attractive magazine. The use of
green tinted paper, a new cover design, provision of
new departments, and the frequent use of cuts and
cartoons have been utilized. The advertising has been
kept on the same high standard of previous years.

The editorial policy has been determinedi but has
: avoided compromising the State Medical Society.

Considerable space is used for publicizing and co-
' ordinating the activities of the various committees.
The activities of the Michigan State Medical Society
and every important decision or action by its officers is
explained in The Journal. The answer to practically
every question asked regarding the state society and its
activities can be answered from The Journal pages.

Important action and expressions from other state
societies are also found on its pages.

County Societies

Interest by our county societies in scientific and civic
matters is gratifying. The activity of local legislative
key-men materially eg.sed the task of our Legislative
Committee during the past session at Lansing.

The program of the postgraduate education continues
to be well accepted, but in view of the excellence of the
subject matter and the rapid dissemination of advanced
scientific knowledge by means of these lectures, an
attempt should be made to increase attendance. To this
end it is suggested that county society secretaries
actively cooperate with their councilors just preceding
and during each fall and spring term of the program.

The M.S.M.S. Secretary’s Letter was sent periodically
to county society presidents and secretaries and four
times during the year to all members.

Michigan Medical Service

The progress of Michigan Medical Service in the
past year will be reported only in brief, as a detailed
report will be presented to the membership of the

August, 1941

corporation (which includes all members of the House
of Delegates).

The ready acceptance of the plan by our citizens has
resulted in the rather rapid growth of Michigan Medical
Service. On December 31, 1940, there was a total of
117,550 individuals enrolled in the various plans. On
July 1, 1941, there was a total of 184,258 individuals
availing themselves of the benefits of Michigan Medical
Service.

The Board of Directors and its Executive Committee
have met at frequent intervals during the past year and
have devoted a good deal of time to the supervision
of the affairs of the corporation. It is believed that the
benefits to the many individuals subscribing to one of
the plans have resulted in a substantial betterment of
their health. The physicians of the state have also
found it satisfactory in that the patients were able to
avail themselves of necessary' medical services when
they were needed, without the prospect of a large bill
to be paid.

At the meeting of the A.M.A. House of Delegates in
Cleveland in June, 1941, resolutions were adopted recom-
mending medical societies to experiment with the princi-
ples of prepaid medical care and making a definite pro-
vision for studies and the setting up of uniform
standards under the direction of the Bureau of Medical
Economics of the A.M.A.

In view of the general interests of the profession
throughout the United States and the steps that have
been taken by many state and county societies in starting
similar plans (many have visited the offices of Michigan
Medical Service to seek information and advice) it is
believed that this step is one of real importance.

Organization

Two new councilors were elected by the 1940 House
of Delegates : C. E. Umphrey, ^l.D., Detroit, First

District, succeeding Henry R. (Jarstens, M.D., who was
chosen as President-elect of the State Society; and
Philip A. Riley, M.D., Jackson, Second District, to
succeed J. Earl McIntyre, M.D., whose term expired.

From October, 1940, through January, 1941, fourteen
District Meetings were held throughout the state
covering all Councilor Districts and all county medical
societies. Good organization in the eighty-three counties
has been maintained, and the county societies seem to
be appreciative of the State Society’s efforts to assist
them with their problems.

The Secretaries’ Conferences of September 25, 1940,
on the occasion of the Annual Meeting in Detroit, and
on January 19, 1941, in Lansing, were well attended, and
aided in imparting information and enthusiasm to the
officers of our component societies.

Committees

The volume of work done by the State Society during
1940-41 is best indicated by the annual reports of the
M.SM.S. Committees. The Council is grateful to all
committee chairmen and members for outstanding serv-
ices performed in behalf of the 4,527 members of the
State Society.

Scientific Work. The extraordinarily fine program
arranged for the 76th Annual Meeting of the Michigan
State Medical Society is best evidence of the praise-
worthy activity of the Committee on Scientific Work.
The inauguration of Discussion Conferences, following
the General Assemblies of W ednesday and Thursday,
will give opportunity to our Michigan men to discuss
their cases and findings with guest-essayists.

Legislative. This was a legislative year, and the
Legislative Committee’s work was the most important
sustained activity of the State Society in 1941. A
total of 51 bills of interest to the practitioner of
medicine had to be watched and. guided by your Legis-
lative Committee whose report is worthy of considera-

639

COMMITTEE REPORTS

]

tion bv every Michigan practitioner. Eighteen weekly
legislative bulletins and three special letters sent to some
350 keymen throughout the State, kept the profession
informed on legislative activity. The Soaety s position
of leadership in medical matters demands an ever-
increasing interest in state affairs, reaching an apex
in the legislative session every second year. Continuous
contracts with, and appreciation of the legislator s co-
operation is indicated. A recommendation on this

subject follows. .

All other State Society committees functioned well
during the past twelve months, as indicated by thei
individual reports published in the Handbook for
Delegates. . .

Thanks are again extended to
and members, without whose work_ the State Societ>
would not have made the progress it has.

Contacts with Governmental Agencies

Contacts with agencies of government, both Federal
and State, continue to be a major, if not the most
^^iportant function of the Michigan State ^ledical

Society.

Preparedness: Medical Preparedness assum^a ^si-
tion of high importance during the past y^r. The State
Society created its Medical Preparedness Committee and
recommended the formation similar committees by
county medical societies with the result that hfty-hve
county preparedness committees now exist, covering all
of the eighty-three counties of the state.

During the past twelve months, the State Society s
Preoaredness Committee was instrumental in stimulating
returns of the A.M.A. Medical Preparednps Question-
naire so that eighty-three per cent of the Michigan
physicians executed this informational document.

A postgraduate course in military medicine was ap-
proved as a function of the M.S.M.S. Postgraduate
Committee during the year.

The remission of dues of doctors of medicine on
active military duty, away from home, was ordered by
The Council, upon authority of the House of Delegates;
seventy-six Michigan physicians were accorded this
remission, as of July 1, 1941.

One thousand eight hundred fourteen (1,814) doctors
of medicine on Local, Medical Advisory, and Appeal
Boards, are now contributing thousands of hours, with-
out compensation, to the federal govenunent as a
patriotic duty. The Society appreciates this sacrifice of
time, effort and expense, and expresses its gratitude to
those who are thus so effectively ser\’ing their country.

The depletion of physicians in certain areas of Mich-
igan is a problem which has been invited to the attention
of The Council several times since January 1 ; in
each instance the cooperation of the A.M.A. Medical
Preparedness Committee has been sought and proper
presentation of the case made to the Sixth Corps Area,
U. S. Army. Deferments, in order to obtain substitutes,
have been granted in a number of instances. This
matter presents a problem to a state like Michigan, with
its cut-over areas and uneven distribution of population.
The mistakes of 1917-18, in depleting some communities
of medical service, should not be repeated in the pres-
ent emergency.

The Council has surveyed reports listing the reasons
why draftees have been rejected by the Selective Service
and have concluded, along with others in various parts
of the country making similar surveys, that the reason
was not non-availability of medical care. A plan of
rehabilitation of rejected draftees is indicated, and
should receive the serious consideration of the House
of Delegates. A recommendation on this subject
follows.

N.Y.A. Health Examination Program: A health ex-
amination of all N.Y.A. trainees, proposed by the Na-
tional Youth Adminisitration last December, was ap-

proved by The Council and put into execution through-
out the state. All trainees requiring remedial work
have been referred to their family physician for this
necessary care.

Afflicted-Crippled Child: The administration of these
laws, and the need for better legislation, was discussed
at every meeting of The Council and its Executive
Committee last winter, leading to the drafting of a bill,
in cooperation with seven other interested agencies.
The introduction and exciting legislative history of this
proposal is detailed in the Annual Report of the Legis-
lative Committee. Unfortunately, certain influences in
the state caused this model bill’s defeat so that the
profession must work, for the present, under the 1937
Crippled Child and the 1939 Afflicted Child Laws.

Effective July 1, the 1937 Schedule of Benefits for
medical care of afflicted and crippled children will be in
operation, with the following limitation made by the
Michigan Crippled Children Commission :

“The fee schedule in operation for medical and
surgical care of afflicted adults in any particular coimty
shall be the fee schedule for the care of children here-
under in that county when such fees do not exceed the
State rate.”

County medical societies having special local arrange-
ments whereby medical welfare, including afflicted adult
care, is given at less than cost price, should give im-
mediate study to definite plans for the early revision of
inadequate schedules. A recommendation on this sub-
ject follows.

County Welfare Contracts : Several progressive county
societies developed or renewed coimty welfare contracts
for medical care of indigents, using the per-capita plan.
Other county societies are urged to study their county
welfare set-ups, and to inform their county welfare
officials concerning the advantages of the per-capita
plan. Action is indicated in view of the study of
medical welfare programs and facilities on which the
State Social Welfare Commission is now embarking.

Medical Practice Act: Amendments to this 1899 law,
to make the Board de jurie instead of de facto as
well as to solve the problem of licensure of midwives,
is urged on the Alichigan State Board of Registration
in Medicine. Changes recommended by this department
of State will find a more favorable reception by the
Legislature than if offered by a voluntary non-govem-
mental agency.

State Department of Health: Very cordial relations

continue to exist with the State Department of Health.
Joint sessions of county society secretaries and public
health officers were maintained, in Lansing on January
19, 1941 and in the northern part of the state on July
16, 1941. The educational work of the field representa-
tives in Cancer, Maternal Health, Child Welfare and
Pediatrics, was continued during the past year through
the cooperative arrangement with the State Health
Commissioner. The State Health Department’s inspec-
tor continued his untiring work’ in the elimination of
illegal practice of medicine, for which he and the De-
partment are highly commended.

Contacts with Non-Governmental Agencies

The State Society continued to strengthen its friend-
ship with other groups interested in the distribution of
medical service to the public, during 1940-41. These
included the Alichigan Public Health Association, the
Michigan State Grange, the American Legion, the Forty
& Eight, Veterans of Foreign Wars, the Children’s Fund
of Michigan, the Alichigan Society for Crippled Chil-
dren, the Alichigan Hospital Association, the Alichigan
Welfare League, the W. K. Kellogg Foundation, Alichi-
gan Hospital Service, the American Mutual Alliance
and the Association of Casualty and Surety Executives.

Michigan Hospitals and Medical Payments Plan: The
two organizations last named cooperated in the de-

JouR. AI.S.M.S.

640

COMMITTEE REPORTS

velopment of a program so that voluntary agreements
providing for liens in accident cases for physicans'
services was put into effect on March 1, 1941. This
program called “Michigan Hospitals and Medical Pay-
ments Plan” more definitely assures physicians of pay-
ment for their services to those individuals who are
injured in accidents, and who, because of their in-
juries, are indemnified by an insurance carrier. The
plan was published in the February, 1941 M.S.M.S.
i Journal The Council feels that this agreement is one
'of the major accomplishments of the past year.

; The Michigan High School Athletic Association in-
augurated during the past year its “Athletic Accident
I Benefit Plan,” to aid high school athletes receive the
I minimum of medical or dental attendance in case of
serious injury during practice or play. Ten thousand
boys (no girls) are enrolled under this plan. Only
' physicians’ and dentists’ bills are paid. A circular
explaining the Athletic Accident Benefit Plan was
I sent to the officers of all county medical societies last
i February.

The desirability of Doctors of Medicine serving as
' physicians to high-school teams is stressed, as the con-
tact with students, their parents, and the faculty is
mutually advantageous — a point which has not been
overlooked by ambitious cultists through the State !

Miscellaneous Business

Intangibles Tax: The question of the liability of a

physician for the payment of that portion of the State
Intangibles Tax relating to Accounts Receivable, which
are based on personal service, was considered by The
Cotmcil during the past year. A legal opinion on this
subject was obtained by the State Society and published
in the Augu'st issue of The Journal.

A.M.A. Delegates: Several matters, for presentation
to the A.M.A. House of Delegates, were discussed by
The Council with Michigan’s delegates to the A.M.A. ;
(a) Specialty Board Resolution adopted by the
M.S.M.S. House of Delegates in 1940. This was re-
ferred by the A.M.A. House of Delegates to its Board
of Trustees for such action as the Board may care to
take, (b) Resolution re Hospital Privileges for Gen-
eral Practitioners. This was re-referred by the A.M.A.
House of Delegates to the Michigan State Medical
Society for further consideration and revision, (c)
Medical Examination of Draftees. This resolution,
urging consideration of reimbursement for physicians,
was disapproved by the A.M.A. House of Delegates,
(d) A.M.A. Trial. Suggestion that the A.M.A. officers
carry this case to the court of last resort was approved
by the A.M.A. House of Delegates.

Beaumont Memorial: The project of purchasing the
house on. Mackinac Island made famous by Doctor
Beaumont’s experiments is resting at the present time
in the hope that the price for the property may drop
to a point where the Beaumont Memorial (Committee
feels it may attempt to finance it. If the property can
be purchased, the Committee feels it should be pre-
sented to the State of Michigan to be cared for by it,
inasmuch as the Committee has unofficial assurance that
the State Mackinac Island Commission would be glad
to receive it and care for the property permanently.

Progress

Renewal of MS MS. Charter for thirty years: Due
to a legal technicality, the Michigan Corporations and
Securities Commission ruled that the renewal of the
M.S.M.S. Charter for another thirty year period must
be approved by the members of the State Society,
through resolutions passed by all county medical so-
cieties. These resolutions have been secured, and a
recommendation on the subject of renewing the charter
follows.

Election of AM A Delegates : The flaw in the election
August, 1941

of four Delegates to the AMA one year, and the
election of only one Delegate to the AMA the next
year, by the M.S.M.S. House of Delegates, together
with the annual confusion over the election of Alter-
nate Delegates, was considered by The Council which
suggested to the Speaker that he appoint a committee
of the House to work out this matter, for presentation
in September, 1941. A recommendation on this subject
follows.

The Michigan State Medical Society with its com-
ponent county societies is the only organization in
this state which exists to protect the physician and his
livelihood. During the past five years it has been able
to achieve results satisfactory to the forty-five hundred
and twenty-seven members of the Society. Eternal
vigilance and professional unity are vital necessities to
our continued enjoyment of freedom.

Unity in the profession means that each individual
idbctor must help his medical organization by allegiance
and support, both financial and by deed. This support
is vital to the organization which in turn is necessary
to its physician-members and to the people whom they
serve.

Recommendations

1. That favorable consideration be given to a resolu-
tion expressing appreciation and gratitude to members
\of the Michigan Legislature and to the Governor for
their courteous reception extended representatives of
the medical profession, and the thoughtful consideration
they gave to medical and health measures coming
before them.

2. That the State Society develop, or join in the
development of, some plan of rehabilitation of rejected
draftees, in which the physician^ patient relationship and
free choice of doctor is maintained.

3. That county societies having arrangements whereby
medical welfare (including afflicted adult) care is given
at less than cost price, be urged immediately to study
and revise their schedules of benefits so that individual
members are not penalized by being forced to perform
services at a financial loss.

4. That approval be given by the House of Delegates
of the resolutions of the State’s fifty-five county
medical societies recommending renewal of the Charter
of the Michigan State Medical Society.

5. That the recommendation of the special committee
appointed to study the problem of election of delegates
and alternate delegates to the AMA, be favorably
considered.

Respectfully submitted,

A. S. Brunk, M.D., Chairman

H. H. Cummings, M.D., Vice Chairman ^

Wilfrid Haughey, M.D., Chairman Publication
Committee

Vernor M. Moore, M.D., Chairman Finance
Committee ^ ^

E. F. Sladek, M.D., Chairman County Societies
Committee

C. E. Umphrey, M.D.

P. A. Riley, M.D.

R. J. Hubbell, M.D.

Ray S. Morrish, M.D.

T. E. DeGurse, M.D.

W. E. Barstow, M.D.

R. C. Perkins, M.D.

R. H. Holmes, M.D.

A. H. Miller, M.D.

W. H. Huron, M.D.

O. O. Beck, M.D.

O. D. Stryker, M.D., Speaker, House of
Delegates

P. R. Urmston, M.D., President

H. R. Carstens, M.D., President-Elect

L. Fernald Foster, M.D., Secretary

641

COMMITTEE REPORTS

ANNUAL REPORT OF THE M.S.M.S.
DELEGATES TO THE AMERICAN
MEDICAL ASSOCIATION, 1941

Your delegates to the American Medical Association
respectfully submit the following report of the 92nd
Annual Meeting of the American Medical Association
held in Cleveland, Ohio, June 2 to 6 inclusive:

The House of Delegates of the American Medical
Association is composed of representatives of the
component state and territorial societies on the basis of
membership ; one representative each from the respective
sections of the Scientific Assembly; one delegate from
the Army; one from the Navy; one from the Public
Health Service ; one from Hawaii, Canal Zone, Porto
Rico and Philippines.

The total registration of Doctors of Medicine at-
tending the Session was 7,269. This was 1200 above the
attendance in the same city in 1934. By sections, the
three highest registrations were in the following order :
Practice of Medicine, first, with 2,440 registrants ;
Surgery, General and Abdominal, second, with 1,147 ;
Obstetrics and Gynecology, third, with 432. There is a
total of 16 sections. The recently created Section on
Anesthesiology had 127 registrations, while an older
section. Pharmacology and Therapeutics, had only 55.

Your attention is called to this tabulation in the
interest of the General Practitioner. Those who oppose
the establishment of a section for the General Practi-
tioner can well ponder the grounds for objections.
If the general practitioners cannot reach third place
in registration next year, it will be because they are
not aware of their privileges.

Each year sees relatively few changes in the personnel
of the Ho-use. Death takes a few, many of whom are
sorely missed for their cool judgment and insight.
During the past year the legislative and administrative
section of the AMA suffered great losses in the death
of Austin A. Hayden, former Treasurer and Trustee;
Charles E. Humiston of Illinois, former President of
the Illinois State Society and a member of the Council
on Medical Education and Hospitals, 1930-37 ; Fred
Moore of Iowa, a member of the House from 1931
to 1940 and a member of the Council on Medical
Education and Hospitals, 1934 — died April 8, 1941 ;
Charles B. Reed of Illinois, member of the House from
1933-40; Howard L. Snyder of Kansas, member
1936-40; Charles J. Whalen of Illinois, member of the
House ifrom 1920-40.

These men have been closely identified with the
activities of the House of Delegates and the delegates
from Michigan learned to love and admire them. We
wish again to join in the sentiment expressed in a
quotation by Dr. Shoulders, Speaker of the House :

“When a star is quenched on high.

For ages will its light
Still travel downward from the sky,

Shine on our mortal sight.

So, when a good man dies,

For years beyond our ken
The light he leaves behind him lies.

Upon the path of men.”

The House usually has three sessions — Monday,
Tuesday and Thursday respectively. Monday is given
over to organization, unfinished business and the intro-
duction of new business. Tuesday is occupied with the
reports of the Reference Committees, the introduction
of further new business and a so-called Executive
Session. The Executive Session rarely, if ever, develops
anything that could not be considered in a regular
session, but the members seem to derive much satis-
faction from the air of expectancy and anticipation that
prevails.

The first business in the House of Delegates is the
642

election of some Doctor of Medicine to receive the
Distinguished Service Award. The Committee on
Distinguished Service Awards submits not more than
five names to the Board of Trustees. In accordance
with Chap. VI, Section 5 of the By-laws, the Board
of Trustees selects three out of the five to be nominated
to the House of Delegates. For the year of 1941, the
House of Delegates elected Dr. James Ewing of New
York City.

Following this election the opening speeches by the
Speaker of the House, Dr. H. H. Shoulders of Nash-
ville, Tennessee, President Van Etten and President-
elect Lahey were made. The Speaker of the House was
later commended for his zeal, both in spirit and per-
formance, which makes it possible that the actions of
the House reflect an atmosphere in which deliberate
judgment and unregimented conclusions prevail. The
Speaker stressed the idealism of our profession and
referred to the first section of The Principals of
Medical Ethics which states that our profession has for
its prime object the service it can render to humanity.
The Speaker catalogued a few familiar qualities wEich
must continue to characterize our membership : integrity,
courage, wisdom, tolerance, ability, and vision. He
intimated that if medicine falls from its high estate as a
profession to that of a trade it will not be by judicial
decree but through a neglect of the eternal values that
have made our profession one for which we are proud
to live and in which we are content to die.

President Van Etten touched pointedly on a number
of matters of great interest to our entire profession.
He emphasized the value of Postgraduate Education and
the necessity of the physician of today to think in terms
of our changing social picture. He also reaffirmed the
recommendation of the Association that a national
department of health be created under director of
cabinet rank. The outstanding contributions of now
Past President Van Etten to organized medicine and
to the science of medicine will be more fully appreciated
as time goes on. His sincerity, his tolerance, his
advocacy of safe principles for the guidance of the
profession and the establishment of equitable pro-
cedures for the distribution of medical care to the
underprivileged should ever be remembered as a guide
for safe and righteous conduct.

President-elect Lahey stressed that more attention be
given to the physical welfare of the association’s offi-
cers, especially that of the occupant of the Presidency.
He also recommended the advisability of keeping young
men coming into the House of Delegates. He further
referred to the necessity of subordinating all trivialities
in the interest of national unity and national pre-
paredness and re-emphasized the unswerving loyalty
of the profession to the nation’s welfare.

Your delegates were instructed by the House of
Delegates of the Michigan State Medical Society in
September of 1940 to introduce certain resolutions.
The one requesting an appointment of a committee to
confer with Specialty Boards regarding the apparent
injustice that arises from the requirement of govern-
mental agencies for specialty board certification for
performance of many medical services paid for by
government funds was introduced by Dr. Christian and
referred to the Reference Committee on Miscellaneous
Business. This committee reported adversely and recom-
mended that MSiMS’s resolution be referred to the
Board of Trustees for its information and such action
as the Trustees may care to take. The House ap-
proved the Reference Committee’s recommendation.

The Resolution on Hospital Privileges for General
Practitioners as developed from the extract of minutes
of the Committee on the Distribution of Medical Care
at its meeting of Alay 7, 1941 and later accepted b}’ the
Executive Committee and given to the delegates to the
AMA to present at the Cleveland meeting, was presented

Jour. M.S.M.S.

COMMITTEE REPORTS

to. the House of Delegates by Dr. Keyport and referred
to the Reference Committee on Miscellaneous Business.
The phraseology of the preamble was provocative of
discussion and the Reference Committee recommended
that the resolution be returned to the Michigan State
Medical Society for further consideration and revision.
This recommendation the House approved.

A resolution referred to the delegates by the Execu-
tive Committee of the Michigan State Medical Society as
a result of a resolution adopted by the Committee on
Distribution of Medical Care recommending pay for the
medical examinations of selectees was introduced by Dr.
Gruber along with a similar resolution from the State
of New York. This was referred to the Reference
Committee on Military Preparedness and was dis-
approved. The House approved the disapproval.

In addition, your delegates have the right to introduce
other resolutions which in their judgment have merit,
and accordingly, at the request of the Section^ on
General Practice of the Wayne County Medical Society,
a resolution was introduced by Dr. Luce requesting the
creation of a section on general practice. This was
referred to the Reference Committee on Sections and
Section Work. The following is quoted from their
report ; “Resolution requesting the Creation of a Section
on General Practice: Careful consideration was given
to the question of establishing a new ‘section for the
general practitioner’. This was felt by the Council on
Scientific Assembly to be undesirable. Your refe-ence
committee discussed the matter in connection with the
resolution presented by Dr. Luce and submits to this
House its belief that an experimental “session” in
The Section on Miscellaneous Topics be established for
the purpose of testing out the plan at the next session
of the Association. If successful in point of attendance
and interest, the question of establishing a permanent
section can then be given further consideration.

Your reference committee feels that the genertal
practitioner constitutes such an important and numerous
factor in the membership of this Association that his
requests should be given due consideration.

If the House reacts favoirably to our suggestion, the
officers appointed to conduct the “session” must be
selected with a view to presenting a program that will
meet the requirements of the situation.”

The report of the Reference Committee was ap-
proved by the House of Delegates. The officers of this
Experimental Section will be appointed by the Council
on Scientific Assembly. A number of doctors from
Buffalo and Western New York together with rep-
resentatives from Wayne County presented arguments
befo’-e the Reference Committee in favor of the adoption
of this resolution. Subsequently about twenty of these
interested doctors met and expressed as their wish that
Dr. Arch Walls of Detroit act as Chairman of this
Section and that Dr. Raymond Fillinger of Buffalo act
as Secretary.

A resolution on Eligibility of Women Physicians and
Surgeons for Medical Reserve Corps of the Army and
Navy was introduced into the House by Dr. Emily D.
Barringer of New York and referred to Reference
Committee on Military Preparedness. (D". Emdy D.
Barringer is the only woman delegate in the House.)
This resolution was sympathetically received but dis-
approved.

A change was made in the Amendments to the By-
laws so that Chapter XV, Section 1 — Item 7, instead of
reading Section on Pharmacology and Therapeutics be
amended to read Section on Experimental Medicine and
Therapeutics.

Regarding the indictment and trial of A.M.A. et ah,
the Board O'f Trustees recommended to the House of
Delegates that counsel for the American Medical As-
sociation be requested and directed to appeal the judg-
ment based on the verdict of guilty against the

August, 1941

American Medical Association in the case of United
States V. American Medical Association et ah. District
Court of the United States for the District of Columbia,
number 63221. This recommendation was unanimously
adopted by the House of Delegates without one dis-
senting vote.

A change in the Constitution was proposed which
must lie over for consideration at the Annual Session
of the House in 1942. The change proposes to increase
the number of trustees from nine to eleven.

Dr. Fred W. Rankin of Lexington, Ky. was nominated
and elected to the office of President-elect without
opposition. Dr. Charles A. Dukes of Oakland, Gal. was
nominated to the office of Vice President without op-
position. Dr. Olin West was again elected Secretary and
Dr. Herman L. Kretschmar was elected to succeed:
himself as Treasurer. Dr. H. H. Shoulders was re-
elected Speaker; Dr. R. W. Fouts of Omaha was re-
elected to succeed himself as Vice Speaker. Dr. Ernest
E. Irons of Chicago was elected to fill the unexpired
term of Trustee of Austin A. Hayden, deceased. Dr.
Charles W. Roberts of Atlanta, Ga. was elected trustee
to succeed Dr. Thos. S. Cullen of Baltimore who
according to the By-laws was not eligible to re-election.

Dr. Frank H. Lahey, President, submitted the follow-
ing nominations for standing committees, which, on
motions duly made, seconded and carried, were con-
firmed by the House : Dr. Walter F. Donaldson,

Pittsburgh, to succeed himself on the Judicial Council
for a term ending in 1946. Dr. Frederick A. Coller,
Ann Arbor, Michigan, to succeed Dr. S. P. Mengle,
Wilkes-Barre, Pa., on the Council on Scientific As-
sembly, for a term ending in 1946.

Dr. Harvey B. Stone of Baltimore was elected to the
Council on Medical Education and Hospitals to succeed
Dr. Fred Moore of Iowa, deceased. Dr. Russell L.
Haden of Cleveland was elected a member of the
Council on Medical Education and Hospitals to fill the
unexpired term of Dr. Fred W. Rankin, resigned.

The House of Delegates selected St. Louis, Mo. in
which to hold the 1944 Annual Session of AMA.

Respectfully submitted,

Henry A. Luce, M.D., Chairman
L. G. Christian, M. D.

T. K. Gruber, M.D.

C. R. Keyport, M.D.

Frank E. Reeder, M.D.

MSMS

ANNUAL REPORT OF THE COMMITTEE
ON DISTRIBUTION OF MEDICAL CARE,
1940-41

The Committee held one meeting on May 7, 1941.

1. The progress of Michigan Medical Service was
discussed.

2. The various maps prepared by S. W. Hartwell,
M.D., showing the distribution of physicians in the
state, relative buying power in different sections of the
state, hospital beds, etc. were discussed. The furthering
of this project in detail was held in abeyance as the
1940 census results were not available and even the 1940
census would be outdated due to the rapid population
shift in the National Defense Program.

3. The resolution concerning general practitioners in
hospitals, which was introduced in the 1940 session of
the House of Delegates and referred to the Committee
for study (Resolution printed in full on page 881 of
November 1940 M.S.M.S. Journal) was referred to the
Executive Committee of The Council with the recom-
mendation of this Committee that it be adopted.

4. After discussion of the feeling in the ranks of
medicine connected with the medical examination of
draftees, a resolution was unanimously adopted, request-
ing that the matter be presented to the A.M.A. House
of Delegates.

643

COMMITTEE REPORTS

5. Other problems presented by the members included
practicing of the physician in hospitals, care of victims
in accidents who have no insurance and in many cases
fail to pay for medical and hospital expenses incurred.
It was pointed out that the same people pay any and
all fines, provide cash for bail and spend considerable
sums to repair wrecked cars and ignore the doctor’s
bill. The Committee is giving further thought to this
problem for later discussion and recommendations.

Respectfully submitted,

T. S. Conover, M.D., Chairman

A. F. Bliesmer, M.D.

H. O. Brush, M.D.

A. C. Henthorn, M.D.

R. F. Salot, M.D.

G. B. Saltonstall, M.D.

H. B. Zemmer, M.D.

MSMS

ANNUAL REPORT OF MEDICAL-LEGAL
COMMITTEE, M.S.M.S., 1940-41

Beginning January 1, 1940, upon instructions of the
House of Delegates, the State Society ceased defending
members in alleged malpractice actions which arose on
and after that date. However, the Medical-Legal Com-
mittee continued to advise members pertaining to the
rights and duties of physicians in the practice of their
profession.

Of the twelve cases referred to your Committee prior
to January 1, 1940, all have been adjudicated to date
except two.

Since January 1, 1941, only one new case (the cause
of action of which arose in 1939) has been reported
to your Committee.

No further action ha's been taken in the two cases
reported in 1940 (the cause of action of which arose in
1939). In one of these matters, it is possible that re-
sponsibility may be assumed by private insurance com-
pany.

In accordance with Chapter Six, Section Four of the
M.S.M.S. By-laws, your Medical-Legal Committee
stands ready at all times to give advice and assistance
to any members of the Michigan State Medical Society
who are faced with medico-legal problems. The
Society will continue its custom of sending malpractice
notification cards to members with their membership
certificates, as a convenience for advising insurance
carriers and the M.S.M.S. Medical-Legal Committee of
any threatening actions.

Respectfully submitted,

S. W. Donaldson, M.D., Chairman

T. E. Hoffman, M.D.

Wm. J. Stapleton, Jr., M.D.

Bert Van Ark, M.D.

E. A. WiTTWER, M.D.

MSMS

ANNUAL REPORT OF M.S.M.S. REPRESENTA-
TIVES TO THE JOINT COMMITTEE ON
HEALTH EDUCATION, 1940-41

The representatives of the Society to the Joint Com-
mittee have had no occasion to meet during the year.

The Chairman, who is also chairman and treasurer of
the Joint Committee, called the annual meeting of the
component units for June 13, 1941. The traditional
activities have been carried on during the past year.
About the same number of health lectures were as-
signed. The radio program, which is a most effective
avenue for the dissemination of health education, has
been ably handled by R. J. Mason, M.D., chairman of
the M.S.M.S. Radio Committee. Arrangements with
the various outlets and the multigraphing and distri-
bution of copy is handled by the Joint Committee.
An interesting exhibit by means of a large chart

644

showing our activities, was presented at the American
Public Health Association meeting in Detroit.

We regret to report that it seems probable that a
lack of adequate financial support will compel the Joint
Committee to discontinue some of its activities. An
activity which has received most favorable comment
is the health column in the Detroit News, which has
been running for nine years. With this health column is
an associated question and answer service which has
grown to large proportions. We believe this to be a
valuable activity, but it is an expensive one. The total
cost runs about twenty-five hundred dollars of which
the Detroit News pays a thousand dollars. Unless
sufficient funds are obtained, this activity wall be dis-
continued. It is planned to go on with the speaking
bureau and the radio programs.

There is no lessening of the need for the dissemi-
nation of factual health information to the laity, but
today there are many organizations and governmental
divisions actively engaged in this work. Twenty years
ago when the Joint Committee was formed there were
few avenues of approach and few groups interested in
this objective. There is no thought of the Joint Com-
mittee discontinuing its activities. It was, however,
suggested at the annual meeting, that in the future the
Committee should lay special emphasis on its function
as an advisory committee on health education. With its
twenty-five component units it has a special opportunity
to serve as a coordinating agency, while at the same
time it carries on as many of its traditional activities
as its budget permits.

Your attention is called to the quite extensive library
of sound and silent films which were purchased by the
Joint Committee. These are available under certain
restrictions, by application to the Extension Division of
the University of Michigan.

Respectfully submitted,

Burton R. Corbus, M.D., Chairman
C. T. Ekelund, M.D.

Henry A. Luce, M.D.

W. R. Vaughan, AI.D.

^MSMS

ANNUAL REPORT OF PREVENTIVE
MEDICINE COMMITTEE, 1940-41

During the year just passed this committee, through
its advisory committees, has witnessed a marked in-
crease in the demands for adequate and immediate
solutions of many new problems that have been posed
before it. Most of this has been created by the all-
pervading national defense program with which pre-
ventive medicine is so intimately interlocked ; but in
spite of the poor definition of many of these problems
the various advisory committees have in most instances
successfully met the demands made upon them.

The expansion of industrial activity, the vast in-
crease in the employed with shift in population, the
concentration of large groups in army camps, have all
served to bring into sharp focus the necessity of pre-
ventive effort in industrial medicine, degenerative
diseases, tuberculosis, syphilis and venereal disease,
maternal and child health and mental hygiene. The
health education of the public through use of the radio,
press and public meetings, and the expansion of facil-
ities for postgraduate education of physicians have also
taken on new importance in the face of the changed
situation.

In addition, an effort was initiated to eliminate what
appeared to be wasteful reduplication in the administra-
tion of certain of the statutes dealing with the lame and
the halt; and, while this 'fell justt short of its mark,
it served to bring to public notice certain glaring
defects that are bound to be eliminated.

Groundwork for the eventual establishment of a
State Bureau of Cancer Control was well laid by the

Jour. M.S.M.S.

COAIMITTEE REPORTS

Cancer Committee and' this group further expanded its
activities into the field of cancer control.

In all deliberations, the committees have had the
helpful cooperation of representatives of the State
Health Department, Children’s Fund of Michigan,
W. K. Kellogg Foundation and the Michigan Tubercu-
losis Association, so that all action taken represents the
combined opinion of all interested groups. The indi-
vidual committee reports present in detail the full action
of each of these groups.

The year was marred by the untimely death of
C. K. Valade, M.D., Chairman of the Committee on
Syphilis Control, whose loss is keenly felt by all
members of the profession.

Your committee held two meetings during the year:
on January 9, and June 19, 1941. In addition, it assisted
in the selection of several speakers for the General
Assembly at the State Meeting.

Respectfully submitted,

Wm. S. Reveno, M.D., Chairman

J. D. Bruce, M.D.

Henry Cook, M.D.

Burton R. Corbus, M.D.

Wm. a. Hyland, M.D.

M. R. Kinde, M.D.

Henry A. Luce, M.D.

R. J. Mason, M.D.

H. Allen Moyer, M.D.

H. H. Riecker, M.D.

W. F. Seeley, M.D.

Frank Van Schoick, M.D.

A. R. WOODBURNE, M.D.

^MSMS

ANNUAL REPORT OF THE RADIO
COMMITTEE, 1940-41

During the past year, twelve radio stations through-
out the state participated with the Society in providing
facilities for broadcasts. These are :

Name of Station

Battle Creek — Station WELL
Aldon H. Haight, Mgr.

Bay City— WBCM
H. A. Giesel, Mgr.

Detroit-Windsor — CKLW
Campbell Ritchie

Flint — WFDF
A. R. Cooper, Mgr.

Grand Rapids — WOOD
Stanley Barnett

Houghton — WHDF
Albert Payne, Mgr.

J ackson — WIBM
Roy Radner, Mgr.

Kalamazoo — WKZO
Patty Criswell, Pub. Rel.

East Lansing — WKAR
R. J. Coleman, Mgr.

Muskegon— WKBZ
Frank Lynn, Mgr.

M arquette — ^WDM J
G. H. Brozek, Mgr.

Port Huron — WHLS
Harmon Stevens, Mgr.

Name of Doctor in Charge

Dr. E. Van Camp
229 Ward Bldg.

Dr. J. Norris Asline
Essexville, Michigan

Dr. G. C. Penberthy
David Whitney Building

Dr. H. M. Golden
Center Building

Dr. P. W. Kniskem
421 Medical Arts Bldg.

Dr. K. J. McClure
Calumet, Michigan

Dr. E. A. Thayer
National Bank Bldg.

Dr. Hazel R. Prentice
458 W. South Street

Dr. L. M. Snyder
City Nat’l Bank Bldg.

Dr. E. N. D’Alcom
Michigan Theatre Bldg.

Dr. N. J. McCann
Ishpeming

Dr. E. W. Meridith
1102 Sixth Street

During this period, the following talks were broad-
cast. These talks have all been in dialogue form wherein
the station announcer asked a question. This was
answered by the physician delivering the talk. The
signature at the beginning and closing of each talk
announced the name of the speaker as a member of
the M.S.M.S.

Following is a list of the broadcasts given: the

common cold, influenza, pneumonia, wintertime acci-
dents, diabetes, sinus disease, the value of x-ray ex-
aminations in accidents and emergency cases, colitis,
artificial fever therapy, relationship of dentistry and
medicine, scarlet fever, eyesight in mental and physical
development, simple facts about how we hear, pre-
marital examinations, importance of pre-natal care, the
menopause, the value of anesthesia in surgery and
medicine, can cancer be cured?, refrigeration treatment
of cancer, the common causes of fatigue, problems in
obesity, anemia, acute abdominal pain, truth and fiction
about blood pressure, misconceptions about heart
disease.

Respectfully submitted,

R. J. Mason, M.D., Chairman
C. L. Grant, M.D.

A. B. Gwinn, M.D.

R. G. Janes, M.D.

G. C. Penberthy, M.D.

^MSMS

ANNUAL REPORT OF COMMITTEE ON
POSTGRADUATE MEDICAL EDUCATION,
M.S.M.S., 1940-41

The Committee on Postgraduate Medical Education
met twice during the year: On January 29, and on

May 21, 1941.

At the first meeting the Michigan Postgraduate pro-
gram in medicine was presented by the Chairman and
discussed by the Committee. The Chairman reminded
the Committee of two actions taken in previous meet-
ings: (1) a motion to allow the Chairman of the

Committee to make changes in the planned program
when emergencies make these changes advisable; (2) a
motion to require the notification of the central office
of the dates of all medical meetings in the state other
than those of county and special societies, so that
conflicts with postgraduate meetings would not occur.

The recommendations of the County Societies’ Com-
mittee of the Council were thoroughly discussed. These
recommendations related to postgraduate medical edu-
cation and were as follows: (1) It was recommended
that a questionnaire be sent to all members relative to
the subject matter of future postgraduate courses.
This has been done in the past and the Committee
recommended that it be continued; (2) It was sug-
gested that an all-d'ay conference given by outstanding
lecturers replace the four weekly meetings. The
discussion of this suggestion brought out several ob-
jections: the increased cost of obtaining speakers;
inadequate time for questions ; hesitancy in asking
questions of strange speakers ; lack of sustained
interest; and the desire of most general practitioners
to have part of the day for . office work and house
calls; (3) The recommendation that examinations
covering the subjects presented over a four-year period
be given before granting certificates of Associate
Fellowship or Fellowship in Postgraduate Medicine,
was set aside for future discussion.

The Committee suggested a Clinical Pathological
Conference to be given at the last meeting of the series.

It was the collective opinion of the Committee that
the present plan of postgraduate medical education is
producing excellent results and that no radical changes
should be made at this time.

Methods of stimulating attendance at the various
centers of teaching were discussed. The Committee
reiterated its belief that the Councilor in each district
should be responsible for stimulating interest in the
postgraduate program, and that the secretary of each
coimty society notify the membership of the Society of
all postgraduate programs.

A communication from Councilors Perkins and
Barstow requested that all of the spring meetings be
held in Bay City, and that all the fall meetings be held

August, 1941

645

COMMITTEE REPORTS

m Saginaw. This request was unanimously granted by
the Committee.

The subjects presented in the extramural course for
October, 1940, and April, 1941, were as follows;
October, 1940.

The Newborn Period.

The Management of Labor.

The Management of Unusual Cases of Hernia.

The Significance of Albuminuria.

The Psychoneuroses.

Laboratory Procedures for Office Practice.

Nasal Accessory Sinus Disease in the Practice
of Medicine.

The Differential Diagnosis of Coma.

April, 1941.

The Care of the Injured.

The Diagnosis and Treatment of Meningitis.

Useful Drugs in Gastroenterology.

Digestive Derangements in Infancy and Childhood.

The Significance of Albuminuria.

Office Gynecology.

Clinical Conference. Diagnostic Problems in Non-
tuberculous Pulmonary Disease.

The registration in the postgraduate courses from
July 1, 1940, to June 30, 1941, is as follows ;

Extramural Registrations — Ann Arbor, 124; Flint,
149; Battle Creek-Kalamazoo, 130; l^dt. Clemens, 78;
Grand Rapids, 177; Jackson-Lansing, 120; Saginaw-
Bay City, 163; Traverse City, etc., 97. Total, 1038.

Intramural Registrations — Allergy, 12; anatomy, 28;
diseases of blood, 14; diseases of heart, 13; electro-
cardiographic diagnosis, 33; gastroenterology, 19;
gynecology and obstetrics, 14; internal medicine (Ameri-
can College of Physicians), 24; ophthalmology and
otolaryngology, 58; pathology, 4; personal courses, 122;
pediatrics, 133; prootology, 21; roentgenology, 19;
summer school, 27. Total, 541.

In addition to the above Ingham County has sub-
mitted a list for postgraduate credits of 131 ; other
physicians qualifying fo.r credits are estimated at 100,
making a total of 231.

The entire number of registrants was 1810.

At the second meeting of the Comm'ttee, on Wednes-
day, May 21, the first matter under discussion by the
Committee was the type of program for teaching in
the extra-mural work. It was the unanimous opinion
of the Committee that the present plan of holding
meetings once each week for four weeks during the
fall and spring be continued. The objections raised to
the one-day continuous session were as follows; 1.
Inability of the physicians to digest mentally eight
lectures in one day. 2. The tendency for the members
tO' tire and leave the lectures so that the last papers are
heard by only a few. 3. The one-day postgraduate
meetings held in Lansing, Flint, Jackson, Kalamazoo,
Highland Park, and other places in the state fill the
need for this type of program, and extension of these
programs would militate against attendance of the
annual State Meeting without meeting the acknowledged
need for the continuity provided in the present eight-
day yearly program.

The idea of correlating and recognizing all post-
graduate activities throughout the state was discussed.
The Chairman suggested that a request for correlation,
recognition and direction by the central office come from
those societies which carry on postgraduate activities.
Dr. R. H. Pino and Dr. Douglas Donald were ap-
pointed to consult with Wayne County Medical Society
relative to this matter.

It was decided by the Committee that postgraduate
work in the northern part of the Southern Peninsula be
concentrated in Traverse City. Also, that Jackson and
Lansing, Battle Creek and Kalamazoo, alternate in
giving the fall and spring courses.

The Chairman called attention to the increased at-

tendance in those districts where the Councilors made
a personal effort to notify the doctors of the meetings,
and he suggested that at the Mackinac Island meeting of
The Council this matter be presented by Councilor
Cummings and Secretary Foster.

Dr. Burton R. Corbus introduced the subject of
graduate training for interns and residents. The
matter of improved medical education and training for
interns and residents was discussed at length by all
members of the Committee and the following motion
passed; The Committee commends and supports the
efforts of the Michigan State Medical Society to
collaborate with the University of Afichigan Aledical
School and the Medical School of Wayne University in
an effort to improve intern and resident training in
Michigan hospitals and in the encouragement of grad-
uate medical education. Aloved by Dr. Donald and
seconded by Dr. Fillinger.

The suggested subjects for the 1941-42 program
were next considered. The following subjects were
approved by the Committee ;

The Modern Treatment of Fractures.

The Recognition and Prevention of Accidents of
Pregnancy.

The Interpretation of Fatigue as a Symptom.

The Office Management of the Allergic Patient.

The Office Management of the Diabetic.

Recognition and Treatment of Rheumatoid Arthritis.

Convulsions in Infancy and Childhood ; their Diag-
nosis and Management.

Emergency Drugs in General Practice.

The Early Diagnosis of Cancer.

Abnormalities of Growth and Development in
Children.

Notwithstanding the slight decrease in attendance in
1940-41, on the whole it has been in the opinion of your
Committee quite a satisfactory year. The imminence of
the war effort, which has called many young men into
service and had a more or less disrupting influence on
those within the age of eligibilitj' for military service,
has prevented many from leaving their homes for post-
graduate study, it is surprising that so many have
continued in their devotion to an improvement of their
service. While the coming year will probably see a
further slight decrease in attendance, we should con-
tinue to provide the usual opportunities for those who
have been availing themselves of these services through-
out the years, and also make an increased effort to
stimulate interest for professional improvement in those
who have been gradually relinquishing their practices,
or have actually done so, thus assuring to the people
the most adequate service possible under the circum-
stances.

Respectfully submitted,

James D. Bruce, Al.D., Chairman

Abel J. Baker, AI.D.

Andrew P. Biddle, AI.D.

Howard H. Cummings, AI.D.

Douglas Donald, AI.D.

Wells B. Fillinger, AI.D.

Charles L. Hess, AI.D.

Henry A. Luce, ALD.

Wm. H. M.arsh.all, M.D.

Edgar H. Norris, M.D.

Ralph H. Pino, AI.D.

Wm. E. Tew, AI.D.

John J. W.^lch, AI.D.

MSMS

Northwestern University Alumni Club luncheon will
be held at the Peninsula Club, Grand Rapids, Thursday,
September 18, 1941, 12;15 p.m. on the occasion of the
M.S.M.S. Convention. E. W. Schnoor, AI.D., presMent
of the Nortwestern Alumni Club of Grand Rapids, will
be chairman. All Northwestern Alumni are cordially
invited.

646

Jour. AI.S.AI.S.

COMMITTEE REPORTS

ANNUAL REPORT OF CANCER
COMMITTEE, 1940-41

The Cancer Committee held four meetings during the
year 1940-41 : on January 6, 1941, February 17, 1941,
March 6, 1941, and June 9, 1941. The objectives of the
Committee for the year were :

1. The drafting of a bill to authorize laboratory
work for the indigent cancer patient at the expense of
the state. This program was to be under the direction
of a committee composed of doctors of medicine
licensed by the State of Michigan and appointed by the
Governor, the work integrated with the Michigan
Department of Health.

2. The maintaining in office of our Field Representa-
tive, who was in the Medical Reserve Corps of the
United States Army, as long as possible during the
present year.

3. The development of a medical brochure on “The
Patient with Incurable or Advanced Cancer” under the
direction of the M.S.M.S. Cancer Committee, the Mich-
igan Department of Health, and the Field Representa-
tive.

I Summary

1. The bill (HB 580) drafted by the Cancer Com-
; mittee with the advice of members of the Michigan

Pathologists Society, the Legislative Committee and the
Executive Committee of the M.S.M.S. Council was en-
dorsed by the Legislative and Executive Committees and
presented to the Governor who in turn arranged for its
introduction in the House of Representatives by a
member of both parties. This bill was assigned to the
Public Health Committee. During discussion on the bill
in this committee, the representative of the osteopaths
(a member of the House Public Health Committee)
insisted that the designation of members of the Cancer
Board, who in the bill were to be doctors of medicine
; and appointed for staggered terms by the Governor, be
i changed to the term “physicians.” During the present
! administration this would not make any difference, but
at some future time, it would make possible the ap-
! pointment of all osteopaths to the Cancer Board ;

I Representative S. L. Loupee, the House member who
sponsored the bill, is also a member of the Public
i Health Committee and objected very strenuously to
this amendment. He felt that he could not be a party
to this bill if such a damaging amendment were ac-
cepted. In discussing this matter with the members
'of the Executive Committee as well as the Chairman
of the Cancer Committee, he decMed not to accept
the amendment ; therefore the bill died in the Public
Health Committee of the House.

2. Doctor Frank Power, our Field Representative,

I was called to' service in April, leaving the last two and
; one-half months of the year unfilled by a Field
* Representative for the combined work of the M.S.M.S.
i Cancer Committee and Michigan Department of Health.

I Health Commissioner H. Allen Moyer, M.D., has been
I extremely satisfied with Doctor Power’s work and
i requests that the position be o-ffered him upon the
fulfillment of his training period. However, this will
1 not be before April, 1942 and in the meantime, the
Committee has leads on two men who are well trained
who a’"e being contacted at this time.

3. The Brochure, “The Patient with Incurable or Ad-
i vanced Cancer,” is an effort to recommend a form of
I treatment for the inoperable and recurrent cancer pa-
tient to eliminate in as far as possible the conversion of

' this patient into an addict of some sort. This brochure
will contain important chapters discussing the mental
approach in announcing to the patient and the patient’s
family the incurability of the disease and the psycho-
! logical methods to be employed with the patient and
! family including environmental arrangements. Other
I chapters will be devoted to methods to relieve pain,

August, 1941

unsightliness, and the employment of various drugs as
far as possible that are not habit forming and when the
latter are necessary, the judicious use of them. This bro-
chure will be completed at an early date for printing at
state expense and distribution throughout the state by
members of the M.S.M.S.

Respectfully submitted,

Wm. a. Hyland, M.D., Chairman
F. A. COLLER, M.D.

W. G. Gamble, M.D.

C. R. Hills, M.D.

A. B. McGraw, M.D.

Lawrence Reynolds, M.D.
William R. Torgerson, M.D.

MSMS

ANNUAL REPORT OF THE CHILD
WELFARE COMMITTEE, M.S.M.S., 1940-41

The Child Welfare Committee has continued the
several projects started under the leadership of F. B.
Miner, M.D.

1. Cooperation with the State Health Department in
formulating and distributing information relative to
immunization schedules. The schedules were brought up
to date and are being sent out two or three times a
year. The revised material is sent to the members of
the M.S.M.S. by the Secretary and to the parents of
newborn babies by the State Health Department.

2. R. M. Kempton, M.D., M.S.AI.S. Representative to
the School Health Committee of the State Department
of Public Instruction, completed his work on “Accidents
in School.” This was reviewed, changed in minor
details and approved by the whole Child V\ elfare Com-
mittee.

3. Lillian R. Smith, M.D. and Warren E. Wheeler,
M.D. of the Maternal Health and Child Health Division
of the_ State Health Department, are continuing their
splendid cooperation in the distribution of incubators
throughout the state. Dr. Wheeler conducts a refresher
course on care and management of prematures in each
district where the State incubators are loaned. This
work has been productive of a tremendous amount of
good. Those who have been fortunate enough to take
part in these courses have been very enthusiastic about
them.

4. With the advice and counsel of the Committee,
Dr. Wheeler prepared a very fine brochure on Measles.
This was printed by the State Health Department and
distributed in volume to local health departments who in
turn distributed them to the practicing physicians in
their district.

A similar brochure is being developed by Dr. Wheeler
and Dr. Pearl Kendrick on Whooping Cough. This,
we hope, will be ready for distribution in the Fall.

5. F. B. Miner, M.D. and Frank Van Schoick, M.D.
have been appointed to the Child Welfare Committee
of the Michigan Welfaire League. In this position they
have been valuable liaison men with other groups in-
terested in Child Welfare.

6. The major activity of the Committee this year has
been relative to the Crippled- Afflicted Child problem.
Inasmuch as this was a legislative year, the Committee
felt that certain changes in existing legislation were
imperative. Pursuant to this thought the committee
formulated certain fundamentals and fo" warded them
to the Executive Committee of the Council and to the
Preventive Medicine Committee of the M.S.M.S.

The Child Welfare Committee recommerded toat The
Council transmit to the Governor of the State of
Michigan the following expression of its attitude relative
to the Crippled Children Commission and its problems ;

1. The personnel of the Crippled Children Commiss-on should
be selected solely on the basis of knowledge of and interest in
chddren and their problems. Such persons should not represent

647

COMMITTEE REPORTS

any special group in the community but should be representa-
tive of the people of Michigan as a whole. , . .

2. The function of the Crippled Children Commission should

be to establish policies, and the carrying out of these policies
should be entrusted to a medical administrator with full author-
ity to act. , . , , • i 1

3. The medical administrator should have an assistant to
carry out such business matters as may be delegated to him.

4. The state should be divided into districts and medical
■coordinators be appointed to represent the administ^tor in
such districts in carrying out the policies of the Cnpplea

Children Commission. . . ^ e

5. The present system of requiring the parents of medically

indigent children to sign notes for the

for services rendered under this program should be discon-
tinued.

The Child Welfare Committee recommends that The
Council transmit to the Governor oi the State arid to
the Legislature the following expression of its attitude
relative to legislation providing for the care of the
sick child:

1. There is no basis for separate legislation for the Crippled
and for the otherwise afflicted child. Crippled chddren should
be considered as a specialized group of afflicted children. Ex-
rpert medical care of crippled children is frequently as importa t
as expert surgical care, and medical complications often arise
during the course of orthopedic treatment. The crippled child

2^.^*Sukabie ^enabling legislation should be_

■commission with authority to care for all ®

authority should include the power and obligation to accept
and/or reject cases arising under this act, to supervise their
care, to- establish appropriate fee schedules for services rendered
bv tihvsicians and hospitals, and to arrange the payment therefor.
“^3!^ The personnel of the Commission should be selected solely
■on the basis of knowledge of and interest in children and th^eir
n?obl^r Such persons should not represent any special
grouiTin the community but should be representative of the

'T' Til Sr ii should bj .0 ostsblish

policies and methods, the carrying out of which should dele-
gated to a medical administrator with full authority and
Bponsiffle^ only ito the t-ve whatever medical

or\uIness assistants may be necessary to the proper execution
of his functions.

The Chairman, representing the M.S.M.S. Child Wd-
fare Committee was appointed on 3.
by The Council to study the Crippled and Afflicted
Children problem and to cooperate with the Legis atiye
Committee of the M.S.M.S. in formulating proper legis-
lation pertaining thereto A great
were held in Lansing and Detroit and finally a bill was
drafted which had the hearty support of the seven
interested groups.

The last activity that the Committee embarked upon
is that of Child Health in War. This- is so new to all
of us that the Committee has nothing to report other
than the fact of continued investigation
Respectfully submitted,

Frank VanSchoick, M.D., Chairman
W. C. C. Cole, M.D.

Leon DeVel, M.D.

Campbell Harvey, M.D.

R. M. Kempton, M.D.

Edgar Martmer, M.D.

^MSMS

ANNUAL REPORT OP IODIZED SALT
COMMITTEE, M.S.M.S., 1940-41

The meetings of this Committee are dependent upon
the necessity of urgent business or new developments^

1. The Committee held one meeting during the year
and that was on November 13, 1940.

At that time a report was given by the Chairman of
the lengthy testimony which he introduced, in collabora-
tion with Mr. Wilcox, Chairman of the Standard-
ization Committee of the Salt Producers Association
and their attorney, Mr. Westcott, at a hearing of the
Federal Food and Drug Administration in Washington
on October 30, 1940. A copy of this testimony to-

gether with collaborative testimony given by Dr.
Walter T. Harrison, Senior Surgeon of the United
States Public Health Service, and also testimony given 1
for the Government by Dr. George Dobbs of the Drug
Division of the Food and Drug Administration, are
hereby submitted.

Since that hearing no further action or regulation has
come out of the Food and Drug Administration except
a verbal order that no therapeutic statement can be
printed on the label of any package of iodized salt
nor can any statement or advice accompany the package.

2. Since the last meeting of the Michigan State Med-
ical Society, the Trustees of the American Public
Health Association accepted the Michigan Committee's
invitation for the formation of a Study Committee on
Endemic Goiter and such has been organized, as a
Sub-committee under the Sub-committee on Evaluation
of Administrative Practices with Dr. Haven Emerson
as Chairman.

This sub-committee at the present time is made up
of the following members :

George N. Curtis, M.D., Professor of Surgery, Dept
of Research Surgery, Ohio State University, Columbus,
Ohio; E. B. Hart, Ph.D., College of Agriculture, Uni-
versity of Wisconsin, Madison, Wis. ; Roy D. McClure,
M.D., Department of Surgery, Henry Ford Hospital,
Detroit; Hugh McCullough, M.D., 325 N. Euclid
Avenue, St. Louis, Mo.; W. H. Sehrell, Jr., M.D., Chief,
Division of Chemotherapy, U. S. Public Health Service,
National Institute of Health, Washington, D. C. ; Harry
A. Towsley, M.D., Department of Pediatrics, University
Hospital, Ann Arbor; W. G. Wilcox, Ph.D., Chairman
of the Standardization Committee, Salt Producers As-
sociation, 154 Bagley Ave., Detroit ; C. C. Yoimg,
Dr.P.H., Director of Laboratories, Michigan State
Department of Health, Lansing; Frederick B. Miner,
M.D., chairman, M.S.M.S. Iodized Salt Committee, 4<X)
Sherman Building, Flint, Secretary of Committee.

Counsultants — Thomas B. Cooley, M.D., Pediatrician,
1728 Seminole Ave., Detroit; David J. Levy, M.D.,
Pediatrician, 768 Fisher Bldg., Detroit; David Marine,
M.D., Research Pathologist, Montefiore Hospital 150 E.
Gun Hill Road, New York; J. F. McClendon, M.D.,
Research Professor of Physiology, Hahnemann Medical
College and Hospital, 235 N. 15th St., Philadelphia.

This national Committee met for the first time at a
two-day Conference in Detroit on June 14 and 15. The
following Agenda was considered. The long report has
not been edited, as yet. It is proposed to bring this to
the Michigan Committee as ■soon as it is completed.

Agenda of first meeting — Jtme 14 and 15, 1941.

1. Brief historical sketches of the work of the
Michigan Committee.

(a) Organization and Plan — Presented by Dr. Cooley.

• (b) Results — Prophylactic — Presented by Dr. Levy.

(c) Surgical — Presented by Dr. McClure.

2. Acceptance, if possible, of etiology of endemic
goiter. Is there any reason to change from the iodine
deficiency theory? Or is there any doubt? Presented by
Drs. Marine and McCullough.

3. Agreement of a plan to ascertain the iodine de-
ficiency by counties or states. Presented by Drs.
Sebrell and McClendon.

4. Agreement of a standard analysis of water and
other test. Presented by Dr. Young.

5. How much supplementary iodine is necessary to
protect persons and domestic livestock living in these
areas and how stabilized? (The same iodine content
in salt for both is in use today). Presented by Drs.
Curtis and Hart.

6. Description of what the State Public Health De-
partments are doing in a preventive way to meet the
problem. Presented by Dr. Sebrell.

7. A proposed imiform plan of prophylaxis. Pre-
sented by Drs. Towsley and Emerson.

648

Jour. M.S.M.S.

COMMITTEE REPORTS

8. A procedure to ascertain the results of pre-
ventive measures. Presented by Dr. Young.

9. The present status of iodized salt with the hederal

Fo(^ and Drug Administration and the Salt Producers.
Presented by Dr. Wilcox and Dr. Miner. j i,

10 Labeling, iodine content, stabilizer used, and the
le^^end statement, “Iodized Salt prevents simple goiter,
as recommended by the Michigan Committee. Presented

by Dr. McClure. r c i*.

^crreement on an official statement for the^ Salt

Produce'rs and the Federal Food and Drug Administra-
tion. Presented by Dr. Levy.

12. Agreement on objectives, allocation and division
of the work. Presented by Dr. Emerson.

All out-state members spoke appreciatively of the
pioneer work accomplished by the Michig^ State
Medical Society’s Iodized Salt Committee Many of
its principles were adopted to apply to the nationa
program.

The most important point, however, adopted by the
national Committee is the recommendation of the use
of a stabilizer in iodized salt and the reduction of the
iodine content from two-hundredths of one per cent to
one-hundredth of one per cent.

The necessity of eliminating the therapeutic statement
from the package of Iodized Salt creates the necessity
for everlasting educational programs for the use of
Iodized Salt by Public Health Departments and by all
members of the profession in all goiterous areas.

Respectfully submitted,

Frederick B. Miner, M.D., Chairman

L. W. Gerstner, M.D.

D. J. Levy, M.D.

R. D. McClure, M.D.

H. A. Towsley, M.D.

S. Yntema, M.D.

^MSMS

ANNUAL REPORT OF THE COMMmEE ON
HEART AND DEGENERATIVE DISEASES,
1940-41

During the third year of its existence, the Commit-
tee on Heart and Degenerative Diseases continued its
policy of directing its educational effort toward the
physician ifi general practice. Its first concern was to
define the broad principles governing the control of
heart disease in children including the reporting of
rheumatic heart disease to the State Health Department
in an effort to determine the incidence of the disease in
Michigan. This culminated in an article appearing m
the M.S.M.S. Journal which covered the principles _ of
the prevention and early care of the rheumatic child.

The classification of heart disease is of first im-
portance in an understanding of the subject. The
Committee has distributed to the members of_ the
Society a short pamphlet dealing with the classifica-
tion of heart disease and the correct method of report-
ing deaths from heart disease so that the vital statistics
of the State will reflect more accurately the incidence
and kinds of heart disease with which the profession

should be concerned.

The Committee also distributed two pamphlets to the
profession — one dealing with the methods of taking
blood pressure readings and the other with the physical
examination of the circulatory system. These pamphlets
had been prepared by a committee of the American
Heart Association and were mailed to each member
through the courtesy of the Michigan Tuberculosis
Association. Since heart disease is now the first cause
of death, these two examinations seem of importance
to the Committee. An explanation of the cardiac
status and the blood pressure enters into the manage-
ment of every patient, in every specialty, before and
after every operation. The medical aspects were par-
ticularly apparent in the preparedness program.

August, 1941

The Committee was influential in obtaining an op-
portunity for the profession to attend courses in heart
disease under the direction of .the Wayne County Con-
tinuation Study Committee and the M.S.M.S. Advisory
Committee on Postgraduate Education. While these
courses were well attended, the Committee is anxious
to secure a still greater attendance by the profession on
short postgraduate courses dealing with the degenera-
tive diseases. Individualized and personal instruction
concerning examination of the heart and the treatment
of patients is fundamental to an understanding of the
subject and this can be best obtained by supervised bed-
side teaching.

Having begun in a small way the educational efforts
in heart disease, the Committee believes that its field
lies in continuing and intensifying this program. The
widespread prevalence of the degenerative diseases
would suggest continuing effort in the educational field.
Some consideration is being given to the problem of
diabetes prevention in this state. It is estimated that
there are fifty thousand cases of glycosuria in Michi-
gan, including about one hundred who are doctors. The
success in this field achieved by Doctor Elliott Joslin
in the Southwest should encourage us in our local ef-
fort. A beginning already has been made by means
of postgraduate programs throughout the State toward
practical instruction in the management of this great
group of people.

Your Committee expresses its gratitude for the fine
cooperation of The Council, the Editor of the Journal
and all members who have contributed to the support
of its program.

Respectfull}’- submitted,

Herman H. Riecker, M.D., Chairman
B. B. Bushong, M.D.

M. S. Chambers, M.D.

John Littig, M.D.

E. D. Spalding. M.D.

MSMS

ANNUAL REPORT OF THE MATERNAL
HEALTH COMMITTEE, 1940-41

Several matters of importance have been considered
by the Maternal Health Committee during the year
1940-41. The collection of data concerning hospital
care of maternity patients in Michigan hospitals and
maternity homes has been considered and submitted to
the Committee. The data have been carefully analyzed
and the complete report will be presented by a com-
mittee member, Alexander M. Campbell, M.D., before
the Section on Obstetrics and Gynecology at the annual
meeting in Grand Rapids next September. There is
much of interest in the data collected and many lines
and many avenues of approach for maternity care in
Michigan are open. This report should be of interest
to all those concerned in the care of pregnant women.

The case of People vs. Hildy (Mich. N. W. 829)
has brought to light ithe interesting and incredible fact
that while it is necessary for a physician to have a
license to practice obstetrics in the State it is not neces-
sary for a mid-wife to be so licensed. This condition
of affairs has been reported to the parent Committee
on Preventive Medicine.

The lack of clinical teaching material in obstetrics
at the University of Michigan has been carefully con-
sidered and a representative has appeared before the
Executive Committee of the Council to discuss ways
and means by which more material for teaching stu-
dents can be made available.

The Committee has been interested in collaborating
with the Michigan Department of Health in the con-
struction of a small inexpensive incubator for pre-
mature babies in the rural districts. The _ result has
been that tivo incubators have been devised which
will apparently answer the purpose.

649

COMMITTEE REPORTS

The Committee has approved the subject of the
State Department of Health in sending Russell R.
deAlverez-Skinner, M.D., into the State for clinics in
postgraduate obstetrics, with the approval of local
medical societies.

At least one more meeting of the Committee will
be held before the annual meeting of the Society in
September at which time the authority in licensures of
maternity homes in the State will be considered.

Respectfully submitted,

W. F. Seeley, M.D., Chairtnan
D. C. Bloemendaal, M.D.

H. A. Furlong, M.D.

N. F. Miller, M.D.

H. W. Wiley, M.D.

A. M. Campbell, M.D., Advisor

^MSMS

ANNUAL REPORT OF COMMITTEE ON
SYPHILIS CONTROL, 1940-41

This year our Committee has had five meetings :
September 26, 1940; November 3, 1940; January 19,
1941 ; March 5, 1941 ; and June 15, 1941.

It was with extreme regret that this Committee,
which had worked so cooperatively together, learned of
the death of our respected Chairman, Cyril K. Valade,
M.D., of a heart attack, on March 27, 1941. We had
all worked together so well under his excellent guidance
that we felt that our committee work had been com-
pletely disrupted. President P. R. Urmston, M.D.,
asked Arthur R. Woodburne, M.D., to complete Dr.
Valade’s unexpired term and we have heartily backed
his efforts to continue the work.

One of our chief interests the past year has been
Venereal Disease Control in areas around 'the various
enlarged military cantonments. In this, we had the
collaboration of the State Health Department’s
Venereal Disease Division through T. E. Gibson, M.D.,
the local County Health Departments, and the private
physicians practicing near the camps. We have dis-
cussed at length and offered our services in venereal
disease control among the soldiers. Dr. Gibson’s report
at our last meeting indicates that the control measures
advised have produced extremely gratifying results
with the incidence of venereal diseases among the
troops in the Fort Custer area being kept at a very
low level.

This year our Committee has worked constantly to
have standard regulations for reporting of venereal
diseases made mandatory at all laboratories — ^both the
private laboratories and those supported by public
funds. Some progress has been made in this direction.

B. W. Carey, M.D., Medical Director for this district
of the N.Y.A., was with us on several occasions and
we devoted a good share of one meeting to outlining
a policy concerning projects to be approved and meth-
ods to be employed in surveys and advice to the youth
of the N.Y.A. and their parents, in matters of venereal
disease control.

Dr. Carey has agreed to undertake the survey of our
venereal disease situation as it affects the “Idlewildl”
area in Lake County, Michigan. This is to be done
when he feels that results will be most conclusive and
when he can best fit it in with his program.

During the early part of the legislative session, some
effort was made to modify the premarital law. This
Committee watched this legislation and with the aid of
the M.S.M.S. Legislative Committee was influencial in
keeping the bill from being reported out of committee.

Our Committee has worked with the Michigan
Pharmaceutical Association through their representa-
tive, Mr. Otis Cook, to completely review House Bill
No. 129, a bill to regulate and properly control the
sale of prophylactic appliances for the prevention of
venereal diseases. The Committee recommended that
the Michigan State Medical Society support this bill.

650

Dr. Gibson, of the Michigan Department of Health,
holds a captain’s commission in the Medical Reserve
Corps, and our Committee felt that because of his
importance in the State with so many defense and
cantonment areas, that his retention in his present
capacity with the State was imperative. A resolution to
this effect was drawn up and we have Dr. Gibson still
with us and it is the hope of our Committee that he
will be left with us and not called into Federal Servdce.

Drs. Roehm and Rice in their subcommittee work
have made every effort to stimulate interest in venereal
disease control through the County Medical Societies.

Dr. Woodburne has prepared outlines of talks to be
used by speakers using our new sets of slides for both
professional and lay education in venereal disease con-
trol. Slides for both groups in sets of about seventy
each are now available to any member of the Michigan
State Medical Society. With these slides are furnished
the outlines for talks for all types of programs, and
various grouping of slides may be used to suit any
size or type of audience. These slides and outlines may
be obtained by writing to any member of this Committee
or the executive offices of the Michigan State ^Medical
Society, 2020 Olds Tower. Lansing.

This Committee has had a very pleasant .year serving
the Michigan State Medical Society in our present
capacity and hope that our efforts will be continued
by our successors.

Respectfully submitted,

Arthur R. Woodburne, M.D., Chairman
Robert S. Breakey, M.D.

Eugene A. Hand, M.D.

J. W. Rice, M.D.

Harold R. Roehm, AI.D.

Loren W. Shaffer, kl.D.

MSMS

ANNUAL REPORT OF INDUSTRIAL
HEALTH COMMITTEE, M.S.M.S., 1940-41

Immediately after the 1940 Annual Meeting, the
Industrial Health Committee held its first meeting in
Detroit. In the discussion at that time, the Committee
came to the conclusion that sufficient programs of
education of the profession had been developed, but
that same should' continue throughout the year. These
programs have continued by the use of speakers on
the postgraduate course of the Michigan State Medical
Society. A seminar was held by the University of
Michigan Department of Public Health in which mem-
bers of 4he Committee participated. Other meetings
were held in the State which were entirely devoted to
the subject of industrial health. Numerous regular
county medical society meetings were also devoted
to the subject of industrial health.

It has been slow work to develop a great amount of
active interest in industrial health, but the Committee
believes that the medical profession of Michigan today
is more interested than ever before in industrial health.

While the Committee feels it is not the responsibility’
of the medical profession to endeavor to stimulate in-
terest in health work among industrial organizations,
still it does feel that there is great need for this type
of work to be done. With this in mind, the Chairman
was authorized to* contact the Michigan Manufacturers’
Association, thru Mr. John L. Lovett, Secretary, who
evidenced considerable interest. After consideration
by the Board of Directors of the Alanufacturers’ Asso-
ciation, a special committee composed of Air. Lovett,
Mr. Kenneth Bowers and Mr. Seth Babcock represent-
ing the Association was appointed. This committee
met with_ the Industrial Health Committee of the
M.S.M.S. in Lansing on April 9, 1941. After thorough
discussion it was decided that the initiation of a pro-
gram of industrial health in two industrial counties of
Michigan in which smaller industries predominated.

Tour. M.S.AI.S

COMMITTEE REPORTS

would be worth while. The industrial health problem is
generally well handled! in the larger industrial organiza-
tions, but very often more or less neglected by many
smaller plants. Two counties were selected for the
experiment because of the active county medical society
and because of the diversified small industrial organ-
izations operating in these two counties. The tentative
program was immediately approved by the Executive
Committee of The Council, M.S.M.S., whereupon let-
ters explaining the program were sent to the officers
of the two county medical societies. The societies now
have the proposed program under consideration and
upon their approval the representatives of the Michiglan
Manufacturers’ Association in these counties are readly
and willing to cooperate in this experiment of educating
the small industrial organizations to the advantages of
a sound industrial health program. The Committee
hopes that with the cooperation of the Michigan Manu-
facturers’ Association this end may be brought about in
all of the industrial plants of the state, particularly
now when every possible precaution should be taken to
preserve much needed man-power in the stress of the
present national emergency.

Respectfully submitted,

Henry Cook, M.D., Chairman
Norman H. Amos, M.D.

Dean C. Denman, M.D.

H. H. Gay, M.D.

C. D. Selby, M.D.

George VanRhee, M.D.

^MSMS

ANNUAL REPORT OF THE COMMITTEE
ON TUBERCULOSIS CONTROL,

M.S.M.S., 1940-41

The Tuberculosis Control Committee has developed
a small card entitled! “Tuberculosis Case Finding”
which may be used by the physician as an easily avail-
able reference. It contains in a few sentences the
pertinent facts regarding tuberculin testing, x-rays, hos-
pitalization and laboratory diagnoses. The card may
be placed in a conspicuous place in the physician’s office
for ready reference.

The desirability of having one meeting per year in
each county medical society devoted to the subject of
tuberculosis, and preferably in one of the available
sanitariums, was stressed. Many of the county societies
have done this diuring the past year.

The Committee recommended that monthly abstracts
of the Tuberculosis Society on the subject of tubercu-
losis be published in The Journal of the Michigan
State Medical Society. The possibilities of doing this
are being investigated.

A list of speakers on tuberculosis was developed for
the speakers’ bureau of the Joint Committee on Health
Education.

Respectfully submitted,

M. R. Kinde, M.D., Chairman
John Barnwell, M.D.

L. E. Holly, M.D.

W. L. How'ard, M.D.

Willard B. Howes, M.D.

Bruce H. Douglas, M.D., Advisor

MSMS

ANNUAL REPORT OF COMMITTEE ON
MEDICAL PREPAREDNESS, 1940-41

There has been no occasion to call together the Com-
mittee on Medical Preparedness since we met for
organizational purposes, there being no matters of
policy to come before us.

The brunt of the Committee’s activity comes on the
chairman. In the early fall the chairman, together with

August, 1941

the chairman of similar committees throughout the
country, was called to Chicago for a conference. Since
that time he has been in very frequent touch, by
letter and! by telephone, with Doctor Olin West of the
American Medical Association, on matters concerning
medical preparedness, and has served as an advisor,
on a great many occasions, to Lt. Col. H. A. Furlong,
M.D., State Medical Officer of Selective Service in
Michigan.

The major task assigned to the National Prepared-
ness Committee by the House of Delegates, was to
make a complete survey of medical persoimel to deter-
mine the number of physicians available for service in
various capacities — for active service, for emergency
conditions, for special fields of medicine, for indus-
trial diefense, etc. Questionnaires were sent to the
6,613 physicians listed in the A.M.A. Directory as of
April 1. We have turned in 88 per cent for classi-
fication. The Preparedness Committees which were
early set up in each county have been of invaluable aid
in following up these questionnaires. Later, an attempt
through a second questionnaire was made to ascertain
how many and what physicians might be available for
service with the military forces, and what physicians
were essential for community needs. Questionnaires
were sent out to the various coimty preparedness com-
mittees who did the best they could to fill out the
blanks satisfactorily. It seemed to us that the ques-
tionnaire might have been worded more satisfactorily.
The county chairmen and county committeemen found
it embarrassing to designate individuals who were so
essential for community needs that they should not be
permitted to volunteer for service, or be called into the
service, and equally embarrassing to designate men who
should be available for military service. However, they
did their best, and on the whole the information so
obtained was valuable.

It is certain that the activity of the State Society’s
Preparedness Committee will be increased as, at an in-
creasing tempo, the government makes its preparation
for defense.

Many of our reserve medical officers who were called
to active service, were practicing in communities where
they were most essential for community health. Very
earnest effort, which involved much correspondence and
telephone communication, has been directed to holding
these men in their communities. In more than one
instance we have gone up to the Surgeon General,
and have, from time to time, asked for aid from the
Governor of the State and from the A.M.A. In gen-
eral we have not been successful in reitaining these men.
While we had no difficulty in establishing the com-
munity’s needs, the army felt that its needs we^-e great-
er and called our attention to the fact that these com-
munity needs should have been recognized by the
reserve officer himself during the period when the
opportunity was given to him to resign.

About half of our physicians are engaged in the
task of examining selectees for the draft boards. With
a self-sacrificing spirit of patriotism the profession
takes on this work without remuneration, and once
again gives evidence that it recognizes that as a pro-
fession it has a very special responsibility to society and
to the state.

Respectfully submitted.

Burton R. Corbus, M.D., Chairman

L. Fernald Foster, M.D.

F. G. Buesser, M.D.

H. H. Riecker, M.D.

A. B. Smith, M.D.

P. R. Urmston, M.D.

651

COMMITTEE REPORTS

I

ANNUAL REPORT OF ADVISORY
COMMITTEE TO WOMAN’S
AUXILIARY, 1940-41

During the past year no important questions have
arisen necessitating a meeting of the members of this
Committee. At varicxus times a few relatively un-
important matters were discussed with the President
of the Woman’s Auxiliary.

Respectfully submitted,

R. C. Jamieson, M.D., Chairmcm
C. W. Brainard, M.D.

L. C. Harvie, M.D.

Wm. S. Jones, M.D.

Edwin Terwilliger, M.D.

MSMS

ANNUAL REPORT OF THE ETHICS
COMMITTEE, 1940-41

The Ethics Committee of the Michigan State Medical
Society is pleased to announce that no occasion arose
during the past year for holding any meetings to dis-
cuss any alleged infractions of the Code of Ethics of
the A.M.A.

One very minor incident, involving three or four
letters, ironed out a question in the mind of a young
doctor who was buying the office of a deceased
physician.

From the excellent behavior of the members of the
Michigan State Medical Society during the past few
years, the job which this committee holds might be
likened to that of the last five vice-presidents of a
bank — an honorary title with nothing much to do.
However, like the vice-presidents, we are willing to
take off our coats and fight a fire if one breaks out.
We will not, according to past custom, answer the
alarm unless we receive notice of the alleged fire in
writing with the assurance that the writer of such
notice will be willing to offer his proof that such an
affair exists.

Respectfully submitted,

Horace Wray Porter, M.D., Chairman

M. G. Becker, M.D.

F. M. Doyle, M.D.

J. J. McCann, M.D.

Allan McDonald, AI.D.

MSMS

ANNUAL REPORT OF THE MENTAL
HYGIENE COMMITTEE, 1940-41

The Committee has had only one regular meeting
during the past year. No program was developed be-
cause it had previously been determined that the Com-
mittee should limit its activities to matters referred
tO' it by the Council or Executive Committee and none
has been referred.

The Committee has been deeply concerned about the
mental health problems of the selectees and also with
the selectees who' have been rejected as unfit for gen-
eral military service by reason of some mental or
nervous disorder other than organic. We refer here
to the psycho-neurotic, the neurotic and the unstable
personality types.

Many draft boards have still the traditional attitude
of sending a young fellow tO' the army to make a man
of him. Your committee wishes to emphasize to the
medical profession of the State the fact that individuals
’vho have adjusted poorly to civilian life are more than
likely not only to be poor soldiers but actually a danger
from within to organized military forces.

_ The armed forces are not training centers for so-
cial problems; citizens and the medical profession must
be alert to recognize and to recommend for rejection
those who are likely to become psychiatric casualties

652

under stresses of military life and later to become ex- *
pensive charges on the government for psychiatric care
and compensation.

Respectfully submitted,

Henry A. Luce, M.D., Chairman
R. G. Brain, M.D.

Esli T. AIorden, Al.D.

R. W. Waggoner, M.D.

O. R. Yoder, M.D.

MSMS

ANNUAL REPORT OF THE PUBLIC t

RELATIONS COMMITTEE, 1940-41

The major projects of a Public Relations character ,
during the past year were those having to do with ■
legislation and voluntary group medical care. The i,
latter was handled directly by the corporation of
Alichigan Afedical Service.

Due to the character of legislative activity and the a
dispatch with which it had to be executed the publicity ;
attending the 1940-41 program was carried out directly
by the Legislative Committee and the Executive office, j
The procedure was consistent with the established prece- \
dent of the society. \

In order that the legislative program might have its ;
rightful precedence over the other routine society i
activities and to decrease the number of contacts to be ]
made with the various component county medical •
societies, the general public relation functions were ]
discharged largely by the Councilors and officers in the ,
official visits.

The committee members did, however, on many
occasions assist in integrating in their districts various
of the activities of the state society.

The ever-'increasing scope of the State Society
functions will, during the coming year, demand much
of the Public Relations Committee.

Respectfully submitted,

L. Fernald Foster, M.D., Chaiirman

A. E. Catherwood, M.D.

C. G. Clippert, M.D.

H. S. CoLLisi, M.D.

S. W. Hartwell, M.D.

H. C. Hill, M.D.

L. J. Johnson, M.D.

A. H. Miller, M.D.

H. L. AIorris, M.D.

Fred Reed, AI.D.

D. R. Smith, AI.D.

A. W. Strom, M.D.

Monroe Avenue, Grand Rapids, Looking West

Jour. AI.S.M.S.

MICHIGAN’S DEPARTMENT OF HEALTH

HENRY A. MOYER, M.D., Commissioner, Lansing, Michigan

-K

100,000 BIRTHS IN 1941?

Physicians of the state will sign a record number of
birth certificates this year, according to an estimate
based on the first five months of returns from all
eighty-three counties.

From January through May, 38,879 births were
reported this year as compared with 37,570 in the same
period in 1940. On this basis, the number of births for
1941 will exceed 100,000 for the first time in Michigan,
the estimate being 102,350.

The present record year in births was 192^, when
99,940 births were reported. Last year’s total of 99,-
106 w'as only a few hundred short of this all-time high.

At least three factors are responsible for the in-
crease in births this year. Marriages increased last
year, there is a gain in population due to the job
attractions in defense areas (whole families are
moving to Michigan), and many homes are in im-
proved financial situation because of business and
industrial prosperity. In offices and stores women
are leaving their jobs in considerable numbers, often
because their husband’s increased income now
makes it unnecessary for them to work.

Physicians were first required to report births in 1906,
when the duty of filling out original certificates was
placed upon them by law. Previously, births had been
reported by supervisors and by city officials. The
physician’s original certificate ultimately is filed in the
State Health Department vaults at Lansing, where there
are 10,000,000 vital records.

After making out the certificate (within five days
after the birth), the physician sends it to a local

registrar, who is the township, village or city clerk or
full-time city health officer. The registrar makes two
copies, keeping one, sending one to the county clerk, and
forwarding the original to Lansing. Either the registrar
or the county clerk may issue certified copies just as
does the State Health Department.

NEW HEALTH UNITS

By action of their boards of supervisors, Washtenaw
and Kalamazoo counties become the 64th and 65th
counties in Michigan to provide full time health
services.

In both instances, the new health departments will
confront problems created or aggravated by national
defense activities. Kalamazoo county shares the
military-civilian problems of the Fort Custer area with
Calhoun county, which has a full time health depart-
ment. Washtenaw county’s added health responsibil-
ities come chiefly from industrial concentrations,
especially the Ford airplane work under way at
Ypsilanti.

Kalamazoo’s new health unit will be the first city-
county health department in Michigan. In eight counties,
there are both city and county full-time health depart-
ments in operation, but the Kalamazoo department will
be the first with a common director and the same
services available to both city and rural residents.
The director will be Dr. I. W. Brown, health officer of
the city of Kalamazoo who has just returned from a
year’s public health study at Johns Hopkins.

Both the Washtenaw and Kalamazoo departments
were established as of July 1. The director for the
Washtenaw unit will be named later.

WEHENKEL SANATORICM

A MODERN, comfortable sanatorium adequately equipped for all types of medical and
surgical treatment of tuberculosis. Sanatorium easily reached by way of Michigan
Highway Number 53 to Comer of Gates St., Romeo, Michigan.

For Detailed Information Regarding Rates and Admission Apply

DR. A. M. WEHENKEL, Medical Director, City OSfiicec, Madison 3312*3

August, 1941

Say you saw it in the Journal of the Michigan State Medical Society

653

MICHIGAN’S DEPARTMENT OF HEALTH

SMALLPOX AT PORT HURON

Port Huron’s smallpox outbreak in April and May
resulted in some thirty reported cases, most of them
mild, and a wholesale vaccination of school children,
of factory workers and of other adults.

Three physicians were engaged by Dr. A. L. Caller^’,
who serves Port Huron as part-time city health officer,
to assist in free vaccination clinics at the city’s public
and parochial schools. Ninety-five per cent of the
children were vaccinated in school clinics, and many
of the remainder went to family physicians for vac-
cination. In large industries, plant physicians vaccinated
employes, and other adults were vaccinated without
charge at the city health office and at the school
clinics. Nearby schools and communities conducted
vaccination programs also. There were many susceptible
persons in the population, although vaccination had been
preached for years at P.T.A. and other meetings and
the St. Qair County Medical Society had established
a low fee of $1.00 for immunizing procedures.

The first cases were diagnosed April 11, on Good
Friday, in two school girls. The school vaccination
clinics were completed in the latter part of May. On
June 30, three new cases were reported, but apparently
unconnected with others in the outbreak.

Most of the cases were mild, but at least one was
serious. It was that of a 78-year-old man, who had
what Dr. Gallery characterized as “the kind of smallpox
we used to see 35 years ago.”

OBSTETRICS STUDIES OPEN TO FOUR

Open to practicing physicians in the state, four
appointments will be made to the two-week course in

obstetrics offered September 22 to October 4 at the
University Hospital by the University of Michigan
Department of Postgraduate Medicine and the Michi-
gan Department of Health. Reservations should be
sent now to Dr. Lillian R. Smith, director of the
Bureau of ^laternal and Child Health, Michigan
Department of Health, Lansing. There is no fee for
the course. In three years, more than 125 Michigan
physicians have had the training of these postgraduate
courses.

LESS MEASLES IN JUNE

Measles cases reported in June totaled 4,570, less than
half the May total and apparently indicating a quick
end to the 1941 epidemic. The total of reported cases
through June was 68,492, about ten per cent under the
six-month total in the epidemic years of 1935 and 1938.
In those years the reported cases totaled 80,000 for
12 months.

COMMUNICABLE DISEASE REPORTS

Communicable disease reports of the Michigan
Department of Health show that in the first five
months of 1941, pneumonia, tuberculosis, diptheria
and scarlet fever were at lower reported levels than
in 1940.

Among the diseases showing increases were
measles, whooping cough and smallpox. Through
May, there were 81 reported cases of smallpox
compared with 16 for the same period in 1940.

(DUE TO NEISSERIA GONORRHEAS)

g)?i

ilver Picrate,
Wyeth, has a convincing record of
effectiveness as a local treatment for
acute anterior urethritis caused by
Neisseria gonorrheae.’- An aqueous
solution (0.5 percent) of silver pic-
rate or water-soluble jelly (0.5 per-
cent) are employed in the treatment.

Acomplete technique of freatwent and literaturewill besenfupon request

*Silver Picrate is a definite crystalline compound of silver and picric acid.
It is available in the form of crystals and soluble trituration for the prepara-
tion of solutions, suppositories, water-soluble jelly, and powder for vaginal
insufflation.

1. Knight, F., and Shelanski,
H. A., "Treatment of Acute Ante-
rior Urethritis with Silver Picrate,”
Am. J. Syph., Gon. & Ven. Dis.,
23, 201 (March), 1939.

JOHN WYETH & BROTHER, INCORPORATED, PHILADELPHIA

654 Jour. M.S.M.S.

Say you sazu it in the Journal of the Michigan State Medical Society

-K COUNTY AND PERSONAL ACTIVITIES ^

100 Per Cent Club for 1941

Allegan

Luce

Barry

Manistee

Clinton

Menominee

Delta-Schoolcraft

Muskegon

Dickinson-Iron

Oceana

Eaton

Ontonagon

Gogebic

Ottawa

Grand Traverse-

Saginaw

Leelanau-Benzie

Saint Clair

Huron

Saint Joseph

Ingham

Sanilac

Jackson

Shiawassee

Lapeer

Tuscola

Lenawee

Wexford-Missaukee

The above County Medical Societies have cer-

1 tified 1941 membership

for all of their 1940

members. Several more

societies are not on

the 100 per cent roll because of only one de-

1 linquent member.

The following members of the Dickinson-Iron Med-
ical Society attended the one-day clinic of the Wiscon-
sin State Medical Society at Green Bay on April 30:
W. H. Alexander, M.D., E. B. Andersen, M.D., W. H.
Huron, M.D., and D. R. Smith, M.D.

Wm. A. Hyland, M.D., Grand Rapids, Chairman of
the M.S.M.S. Cancer Control Committee, addressed the
Regional Meeting of the Woman’s Field Aiimy for
the Control of Cancer, in Battle Creek on June 20.
His subject was “Cancer Control Legislation.”

^ ^

Members of the Michigan State Medical Society are
cordially invited to attend the sessions of the Eighty-
Ninth Annual Convention of the American Pharmaceu-
tical Association which will be held in Detroit the week
of August 17-23. Convention headquarters will be at
the Hotel Statler.

H: * *

Physicians who are in military service may wish to
cancel their malpractice insurance for the period of
their service. Call the local agent of the company with
which you are insured for information. A refund of
unearned premium from date of induction into service
is being granted by some insurance companies and the
same practice may be followed by others.

* *

The Spring Meeting of the Michigan Pathological
Society was held at Bronson Methodist Hospital, Kala-
mazoo, in June. Cases were presented by Drs. C. I.
Owen, Hazel Prentice, C. A. Payne, Arthur Humphrey,
D. H. Kaump, and D. C. Beaver on the subject “Path-
ology of Serous Membrane, Including Joints, Tendon
Sheaths, Peritoneum, Pleura, and Pericardium.”

The October meeting will be held at Receiving Hos-
pital, Detroit, and will be a seminar type of meeting on
some phase of central nervous system pathology with
Dr. Gabriel Steiner conducting and interpreting.

Ferguson -Droste- Ferguson Sanitarium

*

Ward S. Fargusont M. D. James C. Droste, M. D. Lynn A. Ferguson, M. D.

PRACTICE LIMITED TO
DIAGNOSIS AND TREATMENT OF

DISEASES OF THE RECTUM

*

Sheldon Avenue at Oakes

GRAND RAPIDS, MICHIGAN
Sanitarium Hotel Accommodations

August, 1941

Say you saw it in the Journal of the Michigan State Medical Society

655

COUNTY AND PERSONAL ACTIVITIES

Examination for appointments in the Medical Corps
of the United States Navy will be held as follows :
For Acting Assistant Surgeon for Interne Training:,
October 6 to 9, 1941, inclusive; January 5 to 9, 1942,
inclusive. For Assistant Surgeon: October 6 to 9,

1941, inclusive, and January 5 to 9, 1942, inclusive.
Examinations will be held at all the larger naval hos-
pitals and at the Naval Medical Center, Washington,
D. C. Applications for authorization to take the ex-
amination must be in the Bureau of Medicine and Sur-
gery three weeks prior to the date of the examination.
Write to the Bureau of Medicine and Surgery, Navy
Department, Washington, D. C., for application forms.

— MSMS

SUPPLEMENTARY ROSTER

The following members were certified to the Secre-
tary of the Michigani State Medical Society after the
roster which appeared in the May issue, and the sup-
plementary rosters in the June and July issues of The
Journal had gone to press :

Calhoun

Capron, M. J Battle Creek

Harris, R. H Battle Creek

McNair, L. N Albion

Delta-Schoolcraft

Tucker, A. R Manistique

Gogebic

Maccani, Wm. L Iron wood

Strong, Joseph M Wakefield

Kalamazoo

Snyder, R. F Kalamazoo

Kent

Balyeat, Gordon Grand Rapids

Fellows, Kenneth Grand Rapids

Hardy, Faith Grand Rapids

VandenBerg, Henry Grand Rapids

Wright, Thomas B Grand Rapids

Menominee

Corkill, C. C Menominee

Northern Michigan

Slade, H. G Onaway

Wayne County

Aldrich, E. Gordon Detroit

Bauman, Walter L Detroit

Bergo, Howard L Detroit

Clarke, Daniel M Detroit

Clifford, T. P Detroit

Draves, Edward F Detroit

Edgar, Irving I Detroit

Edmonds, Wm. N Detroit

Ewing, C. H Detroit

Finn, Eva M Detroit

Gannan, Arthur M Detroit

Hulse, Warren L Detroit

Johnston, Charles G ’ Detroit

Keating, Thomas F Detroit

Kennedy, Wm. Y ; Detroit

Kovan, Dennis D Detroit

Krass, Edward W Detroit

MacFarlane, Howard W Detroit

Alooire, James A Detroit

Nosanchuk, Barney Detroit'

Roney, Eugene N Detroit '

Schiller, A. E Detroit!

Schulte, Carl H Detroit '

Sellers, Graham Detroit ^

Shipton, W. Harvey Detroit

Stein, James R Detroit'

Stocker, Harry Detroit

Szlachetka, Vincent E Detroit

Thomas, Delma F Detroit

Thompson, H. E Detroit

Tichenor, E. D Detroit

Toepel, O. T Detroit '

Van Nest, A. E Detroit

Warren, Benjamin H Grosse Pointe

West, Howard G Detroit

Williams, Mildred C Detroit'

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Say you saw it in the Journal of the Michigan State Medical Society

MISCELLANEOUS

SELECTIVE SERVICE EXAMINATIONS

In any hastily conceived and rapidly carried out
project of the magnitude of general conscription for
military service, certain inadequacies of the ma-
chinery are prone to appear. That the accomplish-
ments made to date should reflect more to the credit
of the participants is perhaps obvious. The local
examiner, an important participant, has too frequent-
ly found himself caught in the wake of a charitable
act, damned for his alleged errors and receiving
meager acknowledgement of his efforts.

Administrators of the Indiana Selective Service
System have carried on their job in the face of regu-
latory restrictions too often ill-defined or distinctly
ambiguous. They have needed and have received the
services of Indiana physicians, and frequently they
have tendered their grateful recognition.

The lay public has been prone to judge the results
harshly; they are being led to believe that our men
are soft and incapable of hardship, that our national
standard of health has suffered tremendously since
World War I, and furthermore, due to the discrepancy
of results between the local examining boards and the
induction centers, they tend to discredit the professional
ability of the local doctor. So seriously has the
public taken these examination results that more than
one rejected conscript has found himself unable to
secure industrial employment on his return home.

Increased information should be given the public so
that they may better judge. They need to be informed
that the Army of today requires a superior mental
and physical specimen to that required in 1917, and
thev need further to be informed that rejection for
military service need not disqualify any man for his
usual job in his home surroundings.

As to the rejection of selectees at induction centers,
certain statistics recently issued by Captain Glen Ward
Lee, medical adviser to the Indiana Selective Service
System, need wider distribution with appended ex-
planatory notes.

From November 19, 1949, to April 19, 1941, Indiana
induction centers received 14,193 selectees for examina-
tion. Rejections totaled 2,170 for a rate of 15.2%,
which is comparable to other states of the Fifth Corps
area. The rejections may be classified as follows:

1. Mental and nervous disorders 18.96%

2. Diseases of teeth and gums 15.75%

3. Genito-urinary disease 12.32%

4. Eyes and vision 10.03%

5. Musculoskeletal 9.89%

6. Ear, nose and throat 8.01%

7. Hernia and abdominal organs 7.65%

8. Cardiovascular ' 6.87%

9. Feet 3.25%

10. Lungs and chest 2.47%

11. Skin defects 1.04%

12. Height and weight 95%

13. Endocrine disorders ; 67%

14. Administrative* 1.04%

15. Miscellaneous* 1.10%

*Under Administrative and Miscellaneous causes for rejection
or deferment are included such causes as recent operation,
recent injuries, or recent illness.

In the above rejections, it should be emphasized that
many factors operated other than differences of pro-
fessional interpretation. Doctors cannot be expected to
solve dental regulations which have confused more than
the occasional dentist. The addition of dentists to
local examining boards is welcome help. The high
rate of rejection for psychiatric reasons calls attention
to the emphasis on this phase of induction examination.
On behalf of the local examiner, it must be said that
the form he uses does not bring this special type of

August, 1941

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Say you saw it in the Journal of the Michigan State Medical Society

657

IN MEMORIAM

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(In Affiliation with Cook County Hospital)

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is the first time I have been sued for
any cause whatever, which goes to prove
that one can never tell when or where
lightning may strike.”

OF

critical survey to the foreground. In regard to the
genito-urinary disorders, it is no secret that acute infec- ji'
tions have appeared subsequent to the local examina- ^
tion. It is noteworthy that those regulations well
understood by the local examiner have resulted in a
very low rate of rejection while those with contradic-
tory interpretations have resulted in the major causes
for rejection. It is inevitable that there be diverse
interpretation of physical findings as medicine will
never be an exact science.

We firmly believe that the local examiner is deserv- •
ing of more credit for his voluntary patriotic service.
That he is being irked by unwarranted criticism is not
surprising. Though he has not yet arrived at the place
of refusing his further services, it is easy to see how
he might be provoked to this alternative. — From the ■
Journal of the Indiana State Medical Association, June, '
1941.

jRcmcriam

Francis J. Diamond of Ravenna was born in
Gladstone in 1899. He was graduated from Loyola
University in 1927 and interned at the Illinois Masonic
and the Chicago Polyclinic Hospitals. Doctor Diamond
located in Gladstone with his father, John Alexander
Diamond, M.D., and then moved to Grand Rapids
where he served as resident physician at the Michigan
Soldiers Home for one year. He had been located in
Ravenna only one month when his sudden death oc-
curred, June 21, 1941.

* * *

Alvin H. Rockwell of Kalamazoo was born in
Allegan County, January 7, 1851. He was graduated
from University of Michigan Medical School in 1883.
He first located at Alba, where he practiced for a few
months and then moved to Mancelona. In 1887 he
organized the Northern Michigan Medical Society and
,was made its first president. At Mancelona he had his
first experience in public health work acting as village
health officer. In October, 1889, Doctor Rockwell
moved to Kalamazoo where he was health officer for
the city. In 1918 Dr. Rockwell became full-time Direc-
tor of Public Health and Welfare, in which position he
served until his resignation in 1932. He served as sec-
retary of the Academy of Medicine of Kalamazoo
County in 1899 and as president in 1909. In 1927 he
was elected an Honorary Member of the ^lichigan
State Medical Society and in 1935 was elected an
Emeritus Member, and served as Councillor of the
fourth district for twelve years. He died May 3, 1941.

^ ^ ^

Elwood D. Wilson of Cement City was born in
1870 and was graduated from Michigan College of
Aledicine and Surgery in 1897. He located in Bath and
then moved to Fowlerville. In 1921 he located in
Jackson and practiced there until he retired in 1940.
Dr. Wilson died of burns caused by a high tension
power line on his farm in Cement Cit}' on Tune 19,
1941.

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Jour. M.S.M.S.

658

Say yon sazo it in the Journal of the Michigan State Medical Society

MISCELLANEOUS

RECOMMENDATIONS FOR ROUTINE EX-
AMINATION OF APPLICANTS FOR
MARRIAGE CERTIFICATES

By The M.S.M.S. Syphilis Control Committee

Male

1. History

A. Of syphilis or any suspicious lesion.

B. Of urethral discharge.

2. Examination

A. For skin or mucous membrane lesion. If any
genital lesion he present darkfield, direct or indirect,
should be done at once.

B. Take blood for serodia^osis. If genital lesion
be present and Spirocheta pallida reported “not found”
in darkfield, serologic follow-up to cover a period of
at least six weeks.

C. Strip urethra for possible discharge. If discharge
be present, do not issue certificate until every effort
has been made to ascertain possible presence of gono-
cocci.

D. Do two-glass urine test. If shreds are present
in the first glass, macerate a shred upon a slide and
obtain examination for gonococci.

E. If past history of urethral discharge, do micro-
scopic examination of fresh prostatic fluid for pus.
If pus be present, give provocative tests.

Female

1. History

A. Of syphilis or any suspicious cutaneous lesions.

B. Of vaginal discharge.

2. Examination

A. For skin or mucous membrane lesion. Make dark-
field examination of any such suspicious lesion.

B. Obtain blood for serodiagnosis. If suspicious
lesion be present and Spirocheta pallida reported “not
found” in darkfield, serologic follow-up to cover a
period of at least six weeks.

C. Examination of introitus to determine whether
or not hymen is intact.

D. If intact, take vaginal and URETHRAL smear
for examination for gonococci.

E. If perforate, make examination with speculum
and take cervical and URETHRAL smears for such
examination.

Note: If pus is found in the cervical smear at least
four smears should be repeated at daily intervals dur-
ing which no douches are taken. All of these smears
should fail to demonstrate gonococci before a certificate
is issued. Smears should be taken even if Trichomonas
is demonstrated.

The outline above may under ordinary circumstances
seem formidable to the average physician but in fact
few cases will require follow-up examinations.

Since several instances have occurred in which the
examining physician had certified the applicant, only
to have either gonorrhea or syphilis develop in the
marital partner subsequently, it has been suggested that
this recommended outline be followed.

The history, as outlined in the case of both male
and female, may be obtained with a minimum of time.
The examination may be made briefly but should be
made thoroughly. It take no time to strip a male
urethra and practically none to require the male ap-
plicant to void in two glasses. The examination of
the prostatic fluid is probably not necessary unless a
history of previous gonorrhea is obtained, in which
case it should be done. The same principles apply
to the female.

It must not be taken for granted that the female
may not be or ever have been infected with gonorrhea.

As several questions have been raised since the

86c out of each $1.00 gross income
used for members benefit

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August, 1941

Say you satv it in the Journal of the Michigan State Medical Society

659

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enactment of the law requiring certification for mar-
riage regarding the attitude of physicians with relation
to this law, publication of the outline was requested in
The Journal by the Committee on Syphilis Control
of your State Society.

Equitable fees should be charged and if repeated
examinations are necessary it is reasonable that the
applicant should meet the expense involved to the
examining physician^ However, it has been re-
peatedly called to the attention of your committee
that exorbitant fees have been levied for the mere
taking of blood and this would appear unjustifiable
and unwise from the viewpoint of the profession as
a whole. Certainly it is not within the province of
this committee to suggest or fix the fee to be
charged. A bill to fix the fee for the examination
was introduced in the state legislature and fortu-
nately was defeated.

It is suggested that since most of these potential
new families will in all probability become permanent
patients of the examining physician, and since the aver-
age marriage applicant is not in the higher income
brackets, that the good will principle in this matter
contributing to human happiness and the establishment
of a new social unit be considered.

Your committee is at all times open to suggestion
and sincerely hopes that you will communicate with
it either through the offices of the Michigan State
Medical Soceity or through the office of the chairman.

Arthur Woodburne, Chairman

Harold R. Roehm

Loren W. Shaffer

Robert S. Breakey

Eugene V. Hand

J. W. Rice

★

NOTICE TO COUNTY SOCIETY SECRETARIES

Honorary, Retired, and Emeritus Membership
in the Michigan State Medical Society: Please
certify to the Executive Office, 2020 Olds Tower,
Lansing, no later than August 26, the names of
any members for whom Special Memberships in
the State Society will be sought next September.
The membership records of physicians recom-
mended by county societies for special member-
ships must be checked before final submission to
the House of Delegates.

★

660

.S' ay you saw it in the Journal of the Michigan State Medical Society

Jour. M.S.M.S.

THE DOCTOR’S LIBRARY

THE DOCTOR’S LIBRARY

1 Acknowledgment of all hooks received will he made in this
i column and this vkll he deemed hy us as a full compensation
I of those sending them. A selection will he made for review,
^ as expedient.

ACCIDENTAL INJURIES. The Medico-Legal Aspects of
Workmen’s Compensation and Public Liability. By Henry
H. Kessler, M.D., Ph.D., F.A.C.S., Medical Director, New
Jersey Rehabilitation Clinic; Formerly Medical Advisor, New
Jersey Workmen’s Compensation Bureau; Attending Ortho-
paedic Surgeon, Newark City Hospital, Newark Beth Israel
Hospital, Etc. Hasbruck Heights Hospital, Hospital and
Home for Crippled Children; Member, Council of Industrial
Health of the American Medical Association; Hunterian Lec-
turer, 1935; Fellow of American Public Health Association;
Diplomate of American Board of Orthopaedic Surgery; Fel-
low of American Academy of Orthopaedic Surgeons. Second
\ edition, enlarged and thoroughly revised. Philadelphia: Lea
t & Febiger, 1941. Price: $10.00.

I This book discusses the medico-legal aspects of ac-
cidental injuries and is principally for the use of
physicians as well as other agencies. The author reviews
practically every disabling condition which occurs as a
result of accident, and after listing the mechanics and
the prognosis goes into considerable detail regarding the
percentage of disability which results from that particu-
lar injury. It is recommended for all medical and social
agencies interested in industrial health.

^ ^

ESSENTIALS OF ENDOCRINOLOGY. By Arthur Grollman,
Ph.D., M.D., Associate Professor of Pharmacology and Ex-
perimental Therapeutics in the Medical School of the Johns
Hopkins University; Formerly Associate Professor of
Physiology and Instructor in Chemistry in the Same Institu-
tion. 74 Illustrations. Philadelphia, London, Montreal: J. B.
Lippincott Company, 1941. Price: $6.00.

The author presents, in this monograph, a critical
evaluation of his subject. He has succeeded in making

Professional Economics

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your income from professional services.

Send card or prescription blank for details.

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clear the practical application of the present-day knowl-
edge of the subject without sacrificing the laboratory
phase to any great degree. It is recommended for those
who seek a more intensive knowledge of endocrinology.
^ ^ ^

SYNOPSIS OF DISEASES OF THE HEART AND ARTER-
lES. By George R, Herrmann, M.S., M.D., Ph.D., F.A.C.P.,
Professor of Medicine, University of Texas; Director of the
Cardiovascular Service, John Sealy Hospital; Consultant in
Vascular Diseases, U. S. Marine Hospital. Second edition.
St. Louis: The C. V. Mosby Company, 1941. Price: $5.00.
This is the second edition of a volume first published
in 1936, adding to^ the previous edition numerous ad-
vances and discoveries of the past five years. For a
handy-sized book it is exceptionally complete and well
illustrated. A new chapter which discusses the exami-
nation of the heart for military servdce is practical and
interesting.

^ ^ ^

FRACTURES AND OTHER BONE AND JOINT INJURIES.
By R. Watson-Jones, B.Sc., M.Ch.Ortho., F.R.C.S. Civilian
Consultant in Orthopaedic Surgery of the Royal Air Force.
Member of War Wounds Committee of Medical Research
Council. Member of British Medical Association Committee
on Fractures. Member of Cotmcil and Chairman of Stand-
ing Committee on Fractures of the British Orthopeadic
Association. Lecturer in Orthopaedic Pathology, Lecturer in
Clinical Orthopaedic Surgery, and Secretai^r of the Board
of Orthopaedic Studies, University of Liverpool. Neurological
Surgeon to Special Head and Spinal Centre, Emergency
Medical Service. Honorary Orthopaedic Surgeon, Royal
Liverpool United Hospital (Royal Infirmary). Visiting
Surgeon, Robert Jones & Agnes Hunt Orthopaedic Hospital.
Consulting Orthopaedic Surgeon, Royal Lancaster Infirrnary,
North Wales Sanatorium, Birkenhead, Hoylake & West Kirby,
Wrexham & East Denbighshire, and Garston Hospitals.
Second edition. A William Wood Book. Baltimore: The

Williams & Wilkins Company, 1941. Price: $13.50.

This is the second edition of a volume first published
a year ago. The changes in accepted treatment both
of infected fractures and war wounds has necessitated
rewriting this entire chapter and, of course, recent other

The Mary E. Pogue School

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Say yon sa-w it in the .Journal of the Michigan State Medical Society

THE DOCTOR’S LIBRARY

developments in chemotherapy and transfusion have
brought considerable change in many parts of this book.
It is an English type o'! book with profuse illustrations
and considerable thoroughness. The chapter referred to
above on “Open and Infected Fractures and War
Wounds” is well worth reading by every general
pradtitioner. And to the man interested in fractures
the text should be of much value.

^ *

AN INTRODUCTION TO MEDICAL SCIENCE. By William
Boyd. M.D., M.R.C.P. (Edin.), F.R.C.P. (Lond.), Dipl.
Psych., F.R.S. (Canada); Professor of Pathology and Bac-
teriology in the University of Toronto, Toronto; Formerly
Professor of Pathology in the University of Manitoba;
Pathologist to the Winnipeg General Hospital, W^innipeg,
Canada. Second edition, thoroughly revised. Illustrated with
124 engravings. Philadelphia: Lea & Febiger, 1941. Price;
$3.50.

This is a textbook intended for nurses written from
the standpoint of the basic sciences. It is the type of
presentation which makes the orientation of the student
nurse much more complete than the usual textbook can.
The medical treatment is not emphasized but the part
that nursing care plays is completely presented. This
volume is recommended to the teaching of nurses and
for those who must have some knowledge of medicine
without a complete study of the basic sciences.

^ ^

*MODERN SEROLOGICAL TESTS FOR SYPHILIS. And
Their Interpretation by the Physician _

This booklet is a timely review in detail of the
various serological tests on the blood and spinal fluid
for syphilis. Of special interest to the student and
laboratory physician is the technique used in the various
complement fixation and flocculation tests ; and the
comparison of the accuracy and specificity of these
tests. Any physician interested , in syphilis will profit
from a study of the portion dealing with the inter-
pretation of the tests in diagnosis, treatment and prog-
nosis. The discussion of the false positive and false
negatives and their causes and the discussion about the
sero-resistant cases is of interest to all physicians.

* * *

*THE NEWER CHEMOTHERAPY OF VENEREAL DIS-
EASES.

1. Treatment of Gonorrhea with Sulfanilamides and Related
Drugs. By H. S. Young, M.D. ; H. C. Harill, M.D. ;
J. H. Semans, M.D., and O. S. Culp, M.D.

2. Sulfapyradine in the Treatment of Gonococcal Infections.
By R. A. Wolcott, M.D. ; J. F. Machoney, M.D., and
C. J. Van Slyke, M.D.

3. Value of Sulanilamide in Gonorrheal Arthritis. By O. S.
Culp, M.D., and H. S. Young, M.D.

4. Venereal Lymphogranuloma. Results of Sulfanilamide
Therapy. By W. E. Graham, M.D., and E. W. Norris,
M.D.

5. Treatment of Venereal Lymphogranuloma with Sulfanila-
mide. By A. W. Grace, M.D., and F. H. Suskind, M.S.

6. Sulfanilamide Treatment of Chanchroid. By O. S. Culp,
M.D., and C. E. Burkland, M.D.

Sulfathiazole, sulfapyradine, and sulfanilamide are, in
the order given, of great value in the treatment of
gonorrhea. Sulfathiazole is the best because of its
low toxicity and its marked bactericidal and bacterio-

static effect in the urine. It often is able to cure in

cases resistant to the other two drugs. Sulfapyradine
is of value in those cases resistant to sulfanilamide
and also in fresh cases. It was found to be as efficacious
in chronic cases as in acute ones. Of twenty-two hos-
pital cases with gonorrheal arthritis 68 per cent were
cured or markedly improved with sulfanilamide therapy.
The results were more striking in the acute cases.

Sulfanilamide is of value in all types of venereal
lymphogranuloma. Surgery in this disease should be
limited to opening the fluctuant buboe and to relief of
rectal stricture.

Sulfanilamide is a rapid and efficacious method of
treating complicated and uncomplicated chancroid.

*These booklets are available without charge to all members
of the Michigan State Medical Society by request to Dr.
Gibson, Michigan Department of Public Health, Lansing, Mich-
igan.

LETTERS TO THE EDITOR

Editor, Journal Mich. State Med. Society.

My dear Sir :

Although it is somewhat early, we want to start
talking about our big book for November, THE
DOCTORS MAYO.

“The Mayos” is a household word the country over —
the Mayo story an American epic which has not been
told. Everyone has heard of Dr. Will and Dr. Charlie,
but the phenomenon of their achievement, the small
town clinic that grew to international fame, has been
little understood. The modesty of the men and their
strict conformity to medical ethics discouraged pub-
licity, and no one was able to publish the story during
their lifetime.

That it would have to be told sometime was inevitable.
During their lifetime neither the Doctors Mayo nor any
of their staff could be brought to undertake it. In the
end, in order to divest themselves of any connection
with it, they authorized the University of Minnesota
to publish, through the University of Minnesota Press,
a book on the history of the Doctors Mayo, the Mayo
Clinic, and the Alayo Foundation. The responsibility
then fell on the university to produce an objective and
balanced account of the contribution of the Mayos and
of their colleagues throughout the world, to medical
science and education.

Full-time exploratory work in Rochester was begun
immediately. Research, interviews, and the accumulation
of source material have been carried on intensively and
continuously for nearly five years. Complete cooperation,
has been extended to the university, but the book now
to be published is an independent study, written by
H. B. Clapesattle, a trained historian and chief editor
of the University of Minnesota Press.

The results have been beyond even our greatest hopes.
In Rochester has been uncovered a rich vein of
Americana. It is at once the story of the frontier and
of a century of medicine in this country, from the days
when hospital patients were nursed by jailbirds to the
current era of aviation medicine. It is the storj^ of how
the Old Doctor Mayo, himself a social and medical
pioneer, passed on to his two sons a passion to learn
from everyone and everything, and how they passed it
on to their colleagues till it became the living spirit of
a great institution. The author has brought all these
elements into focus in an important human drama of
unequaled interest.

We thought you would like to know that this book
is scheduled for November seventeenth and that you
will have further word about it later.

Sincerely yours,

Dorothy A. Bennett
Sales and Promotion Alanager

Physicians' Service Laboratory

608 Kales Bldg. — '
Northwest comer of
Detroit, Michigan

Kahn and Kline Test
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Allergy Tests
Basal Metabolic Rate
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Complete Urine Examina-
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Ascheim-Zonde

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Smear Examination
Darkheld Examination

All types of mailing containers supplied.
Reports by mail, phone and telegraph.
Write for further information and prices.

662

Jour. M.S. M.S

i

ENZYMOL

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These are some notes of clinical application during many years:

Abscess ccxvities
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Sinus cases
Comeal ulcer

Carbuncle After tooth extraction

Rectal fistula Cleansing mastoid

Diabetic gangrene Middle ear

After removal of tonsils Cervicitis

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r

BEFORE TODAY IS OVER

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flammation.

The simplicity and convenience of the Burdick SWD-52 Short
Wave Diathermy widen the range of this effective form of
therapy in your practice. The drum applicator for the induc-
tance cable saves time and avoids pressure on tender areas.
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Minor electrosurgery is available for such procedures
as removal of warts and nevi.

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Address

City State

September, 1941 671

Say you saw it in the Journal of the Michigan State Medical Society

MICHIGAN MEDICAL SERVICE

Each month The Journal has carried an ar-
ticle, and a number of bulletins have been mailed
directly to doctors, setting forth interesting data
about Michigan Medical Service. A resume of
some of the most important points which have
come up for frequent discussion is as follows .

Medical Control and Responsibility

• The House of Delegates of the Michigan State
Medical Society adopted the basic principle that
the prepayment plan to be sponsored by the
medical profession should not be another com-
mercial insurance cash indemnity arrangement
but should be a direct service program.

* * *

• Accordingly, Michigan Medical Service was so
organized that the medical profession has full
control of the administration of the program in
return for putting up their services as a reserve
guarantee to subscribers.

Payments for Services

• The general level of the payments to doctors
for services to subscribers was outlined by The
Council and ratified by the House of Delegates
of the Michigan State Medical Society.

* *

• A Schedule of Benefits in keeping with this
general level of payments, which is equivalent
to the prevailing charge by doctors in Michigan
for persons whose income ranges from $1,500
to $1,700 annually, was carefully set up through
the cooperation of numerous committees in the
various fields of practice.

* * *

• This Schedule is used as a guide for the
authorization of payments by the Medical Ad-
visory Boards, but the payment authorized takes
into consideration the particular services as set
forth in the doctor’s Monthly Service Report.

Experience to Date

• In the short space of sixteen months of opera-
tion, the medical service plan has accumulated
an immense amount of valuable data for the
benefit of the private practice of medicine.

* * *

• Committees from medical* societies in twenty-
two states and Brazil have come to Michigan

MICHIGAN MEDICAL SERVICE REGISTRATION
HONOR ROLL
(As of August 10, 1941)

100 per cent

Manistee

Mason

Mecosta-Osceola-Lake

Menominee

90 to 99 per cent
Bay-Arenac-Iosco
Calhoun
Gogebic

Grand Traverse-Leelanau- Benzie

Marquette-Alger

Oceana

St. Joseph

80 to 89 per cent

Allegan

Barry

Branch

Chippewa-Mackinac

Delta-Schoolcraft

Dickinson-Iron

Eaton

Gratiot-Isabella-Clare

Hillsdale

Houghton-Baraga-Keweenaw

Huron

Ingham

lonia-Montcalm

Kalamazoo

Kent

Lenawee

Livingston

Midland

Muskegon

Newaygo

Northern Michigan

Ontonagon

Ottawa

Saginaw

Tuscola

Wexford-Missaukee

75 to 79 per cent

Jackson

Macomb

Monroe

North Central Counties

Oakland

Wayne

for help in connection with establishing medical
service programs to combat the forces seeking
to disrupt the private practice of medicine.

• Increased good will of the public, the news-
papers, of industry, and of the legislature has
been gained for the medical profession through
the medical service plan.

(Continued on Page 6/4)

Tour. M.S.M.S.

In early childhood

• • •

/^edecLes

CEREvTm

CEREVIM, a pre-cooked cereal food, possesses
those properties desirable in a first solid food
for babies. Babies like it from the start, and because
of its appealing taste, may be expected to con-
tinue eating it through early childhood. It is
easily digested, highly nutritious and smooth in
texture.

B Vitamins and Minerals from Natural Sources

Cerevim’s comprehensive formula provides the
B vitamins in generous amounts. Each ounce con-
tains 100 International Units Thiamine (Bi) and
60 Bourquin Sherman Units Riboflavin (B2).
Calcium, phosphorus, iron and copper are pro-
vided in easily assimilated form; proteins, carbo-
hydrates and fats in a suitable ratio — all derived
from natural sources only.

• ready for instant use;

• advertised only to the medical profession;

• sold only through druggists.

packages:

Cerevim is sold in H and 1 lb. containers.

LEUERLE LABORATORIES, inc.

30 ROCKEFELLER PLAZA • NEW YORK, N.Y.

September, 1941

Say you saw it in the Journal of the Michigan State Medical Society

673

(Continued from Page 672)

• Groups of subscribers have been enrolled in
thirty-eight of the fifty-five county medical so-
ciety areas. Each group of subscribers enrolled
requires at least five months before preexisting
conditions are corrected. During this period, two
to three times more services ore received by sub-
scribers than by persons in the general public.

* * *

• Remuneration for services under Michigan
Medical Service is particularly advantageous in
situations such as the following:

Accident cases where no payment for services
would be available.

Where services have been rendered for years
with no possibility of collecting any charge.

For services rendered to patients who move
out of the state.

Patients who die and leave no estate.

Patients who would ordinarily receive care as
medical indigents.

Late Reporting

• To overcome late reporting of services, it
has been provided that reports must be received
within ninety days from the month of service
to be eligible for payment.

* * *

• For the months of April, May, and June,
benefits have been prorated or tentatively re-
duced 20 per cent until a final determination can
be made of the total volume of services for these
months.

• It is absolutely essential that the Initial Service
Report be sent by the doctor to Michigan Med-
ical Service when the subscriber first requests
services for each illness. This report enables
prompt verification and the sending of a notice
to the doctor if the subscriber is not eligible
for benefits. Likewise, the Initial Service Re-
port permits the setting up of records and
speedier payment on Monthly Service Reports.

* »

• Monthl}^ Service Reports should be sent not
later than the tenth of the following month for
services rendered each month.

Remember — reports received later than ninety
days from the month of services can not be au-
thorized for payment.

Cooperation of Doctors

• The number of doctors registered with Michi- ;
gan. Medical Service has increased each month*
until now over 3,600 doctors are participating.
The distribution of participating doctors accord- :
ing to county location and type of practice com- •
pares very closely with the distribution of doc-<
tors in Michigan.

UNIVERSITY OF MICHIGAN
MEDICAL SCHOOL REUNION

The second triennial reunion for alumni of the Uni-
versity of Michigan Medical School and former Staff
members and house officers of the University Hospital
will be held in Ann Arbor on October 2, 3 and 4.
Faculty members who will participate in the scientific
program are Drs. John Alexander, Carl E. Badgley,
Frederick A. Coller, Howard B. Lewis, Charles F.
McKhann, Norman F. Miller, Louis H. Newburgh, Mal-
colm H. Soule, Cyrus C. Sturgis, Carl V. Weller, and
Udo J. Wile. Alumni speakers and their topics are as
follows: Dr. William L. Benedict, Professor of

Ophthalmology at the University of Minnesota Graduate
School of Medicine and Ophthalmologist at the Mayo
Clinic: Diagnosis and Treatment of Glaucoma; Dr.

Detlev W. Bronk, Professor of Biophysics and Director
of the Johnson Research Foundation, University of
Pennsylvania School of Medicine : Physiological Fron-
tiers in the Medical and Social Sciences; Dr. Charles
L. Brown, Professor of Medicine, Temple University
School of Medicine: Clinical Aspects of Osteoporosis;

Dr. George W. Curtis, Professor of Surgery, Ohio
State University College of Medicine : The Determina-
tion of the Circulating Thyroid Hormone; Dr. Joseph
R. Darnell, Lieutenant Colonel, Medical Corps, United
States Army, Office of the Surgeon General : Concern-

ing Army Medical Service ; Dr. Harold K. Faber, Pro-
fessor of Pediatrics, Stanford University School of
Medicine ; Portals of Entry in Poliomyelitis ; Dr. Tins-
ley R. Harrison, Professor of Medicine, Bowman Gray
School of kledicine of Wake Forest College : Spon- |

taneous Hypoglycemia as a Factor in the Production
of Cardiovascular Symptoms ; Dr. Lyle B. Kingery,
Professor of Dermatology and Syphilolog}', University
of Oregon Medical School : The Significance of Pruri-
tus in General Medicine ; Dr. Perrin H. Long, Professor
of Preventive Medicine, Johns Hopkins University
School of Medicine : Recent Aspects of Bacterial

Chemotherapy ; Dr. Robert T. Monroe, Peter Bent
Brigham Hospital, Boston : Old Age ; Dr. Walter M.

Simpson, Pathologist, Miami Valley Hospital, Dayton,
Ohio: New Developments in the Diagnosis and Treat-
ment of Brucellosis ; Dr. Warren T. Vaughan, Rich-
mond, Virginia: The Allergic Factor in Certain Der-

matoses.

MSMS

There will be 110 technical and scientific exhibits
at the Annual Meeting of the Michigan State Medi-
cal Society at Grand Rapids, September 17, 18, and
19.

MSMS

The Sections are making a special endeavor this
year to present most entertaining and practical pre-
sentations at the Annual Meeting of the Michigan
State Medical Society, September 17, 18, and 19 at
Grand Rapids.

674

Jour. M.S.M.?.

DILUTE MIXTURES

Evaporated milk 4 ozs.

Water, boiled 12 ozs.

Karo 1 tbs.

2 ozs. every 3 hrs. for 8 feedings

Lactic Acid milk (dried) 5 tbs.

Water, boiled 16 ozs.

Karo 1)4 tbs.

2 ozs. every 3 hrs. for 8 feedings

CONCENTRATED MIXTURES

Breast milk 12 ozs.

Evaporated milk 4 ozs.

Karo 1 tbs.

2 ozs. every 3 hrs. for 8 feedings

Lactic Acid milk (2%) . . 16 ozs.

Karo 2 tbs.

2 ozs. every 3 hrs. for 8 feedings

FEEDING PROGRESS

Days

Drams

Ounces of

of

at Each

Feeding

Age

Feeding

per 24 Hrs.

1

1

1

2

2

2

3

4

4

4

6

6

5

8

8

6

10

10

7

12

12

(8 drams = 1 ounce)

Most of the common milk mixtures have been
used at various times with some degree of success
— evaporated, acid and dried milks, and butter-flour
mixtures. Those high in protein and carbohydrate
and low in fat are the most suitable in concentrated
formulas properly adapted to the limited digestive
capacity of the premature. While lactic-acid milk
with addition of 7 to 10 per cent by volume of Karo
syrup yields twenty-five to thirty calories per ounce,
evaporated milk with 5 to 10 per cent added Karo
sjTup is equally effective.

Processed or acid milks are advantageous because
of the fine curds produced, the premature being par-
ticularly susceptible to curd indigestion. Nonfer-
mentable carbohydrate in quantities similar to those
used in normal feeding of infants may be added to
any of these milks. The formula may be concen-
trated by decreasing the water, or adding powdered
protein nulk in place of extra amoimts of sugar.’*

'Kvgei.M ASS -."Newer Nutrition in Pediatric Practice.**

CORN PRODUCTS SALES COMPANY
17 Battery Btace^ Newv Yorh City ’

September, 1941

675

>f HALF A CENTURY AGO X-

GAH. STONES— A NEWER PLAN OF TREATMENT*

J. R. Williams, M.D.

White Pigeon, Michigan

The subject to which I invite your attention is that of
gall stones. I shall not attempt an exhaustive article
upon this very important, and to me, deeply interesting
subject, but simply touch upon such features in the
diagnosis and treatment as are of practical importance
in the daily work of the busy practictioner, and present
a plan of treatment superior, I think, in every way to
the treatment usually prescribed. The symptoms of
this painful disease are: first, an uneasy sensation,
nausea, and pain located in the right hypochondriac and
lower part of the epigastric region ; persistent vomiting.
The vomited matter that at first consisted of the
partially digested food, soon changes to a glazy mucus,
and often there may appear bilious matter, the contents
of the gall bladder liberated by the passage of the
stone into the duodenum. -

There is usually constipation and the abdomen is
frequently distended by gas, which makes its escape
when a movement of the bowels takes place. Jaundice
is present in the majority of cases and its extent de-
pends upon the degree of obstruction, though there may
be no jaundice — as when the obstruction is in the cystic
duct — and when all the symptoms of gall stones are
present except that of jaundice, which afterward ap-
pears, it is evident that the stone has changed its
position from the cystic to the common bile duct.
Many cases are recorded in which the stone, after its
escape from the bile ducts, finds lodgment in the bowels.
Of course this can occur only when the stone is very
large. The only disorder, with which an attack of
hepatic colic may be confounded, is gastralgia. But
here the distinction is made by the seat of pain, by the
absence of jaundice, and the failure to find concretions
in the stools.

And here let me call your attention to the fact that
in all cases presenting symptoms of bilious colic, the
stools should be examined. A white cloth should be
laid on the ground, the stool emptied upon it, and
washed with water. I well remember a case presenting
all the symptoms of gall stones to which I was called.
The patient informed me that the present was not her
first attack, but when I diagnosed the case to be gall
stones, she stoutly maintained that such could not be
the case, as in this as well as former attacks the pain
was induced by eating mutton. I informed her of
the nature of her disease, prescribed appropriate
remedies, and the result was the finding of a large
number of gall stones in the stool, greatly to my satis-
faction and the relief of my patient. And now, satisfied
of the symptoms, what treatment shall we prescribe?
Gall stones, as we are all aware, are composed largely
of cholesterin, but in normal bile cholesterin is an
ingredient of small percentage. Therefore, before gall
stones can be formed, the bile must become greatly
changed. Its physical conditions are of less importance
than its chemical. There must be an accumulation of
bile in the gall bladder — stasis — and concentration.
These conditions are essential to calculus formation.
Now, what brings about this change in the bile? I

*Presented at the twenty-sixth annual meeting of the Michi-
gan State Medical Society held at Saginaw, June, 1891.

676

am satisfied that this disease has its origin in a
duodenal catarrh, swelling and pressure upon the duct
so closing the duct that the contents of the gall bladder
cannot find exit. The bile becomes concentrated and
stones are formed. Now, what treatment shall we
prescribe? The old treatment consisted of four rules:
(1) Open the bowels. (2) Relieve the pain. (3) Pre-
vent inflammation. (4) Prevent future attacks. Un-
til recently the treatment consisted wholly of anti-
spasmodic antacids and cathartics, and frequent calls
to attend the same patient were the result. Finally,
olive oil was introduced to the profession as nearly a
specific, and certainly many wonderful cures followed
its use, the modus operandi of which no one has dis-
covered. Yet even olive oil sometimes fails. The treat-
ment I propose has certainly proved to be, at least in
my hands, an improvement on all former treatment. I
cannot say that it will be successful in all cases, but
so far as it has been tried, it was a success. When
called upon to visit a patient suffering with bilious
colic where gall stones are suspected, I first give mor-
phine by hypodermic injection, until I have the pain
under control. As soon as my patient is easy, I give
Bower’s or other refined glycerine in doses of one
ounce every two hours until free movement of the
bowels takes place. The result of the internal adminis-
tration of glycerine is a copious evacuation, the stools
frequently containing gall stones and inspissated bile.
I am satisfied that the use of glycerine in these cases,
acts in the same manner as when given per rectum or
vagina, and who, that have used glycerine in this way,
have not been surprised at the amount of waterj^ flow
that takes place? I believe that glycerine depletes the
duodenal mucus and thus liberates the duct that is
pressed uoon.

I believe that in glycerine we have a remedy for this
disease, sure and painless. There are other reasons
that might be given why this remedy acts as it does, but
to me none look so reasonable as the one I have given.

I thank you, gentlemen, for the time I have taken.
I sincerel}'^ hope that you will give this subject your
consideration — the consideration it deserves.

In Lansing

HOTEL OLDS

Fireproof

400 ROOMS

Tour. M.S.M.S.

GOOD

INFANT FEEDING RESULTS

The weight curves above show the normal, uneventful progress of 75 infants fed
Similac for six months or longer — not a select group, but 75 consecutive cases. In no
instance was it necessary to change the feeding because of gastro-intestinal upset. These
curves were taken from hospital (name on request) records. Similarly good results
are constantly being obtained in the practice of the many physicians who prescribe
Similac routinely for infants deprived, either wholly or in part, of mother’s milk.

A powdered, modified milk product especially prepared for infant feeding,
made from tuberculin tested cow’s milk (casein modified) from which part of
the butter fat is removed and to which has been added lactose, vegetable oils
and cod liver oil concentrate.

SIMILAC )

M&R DIETETIC LABORATORIES,

September, 1941

SIMILAR TO
BREAST MILK

NC. • COLUMBUS, OHIO

Mm Yhb CpuftPH yp Oi-4ei‘

A. GRAYBRUCK
(Mosby Representotive)

1441 Webb Avenue
Detroit, Michigan

Gentlemen: Please send me the book(s) that

1 have checked with (X) Attached is my

check Charge my account. (Terms: $3.00

a month up to $30.00. Where total order exceeds
$30.00 divide by ten to arrive at the amount of
each monthly payment.)

n Meakins — "Practice of Medicine," price $10.00

□ Walker - Elmer - Rose — "Physical Diag-

nosis," price 8.75

□ Clendening - Hashinger — "Methods of

Treatment," price 10.00

□ McGuigan — "Applied Pharmacology,"

price 9.00

□ Scherf and Boyd — "Cardiovascular Dis-

eases," price 7.50

□ Scherf and Boyd — "Clinical Electrocar-

diography," price 7.50

□ Bard — "MacLeod's Physiology in Mod-

ern Medicine," price 10,00

□ Key and Conwell — "Fractures, Disloca-

tions and Sprains," price 12.50

□ Brickel — "Surgical Treatment of Hand

and Forearm Infections." price 7.50

□ Titus — "Obstetric Difficulties," price. . . . 10.00

□ Sutton and Sutton — "Introduction to

Dermatology," price 9.00

□ Ritchie — "Essentials of General Sur-

gery," price 10.00

D Crossen — "Diseases of Women," new

edition, price 10.00

□ Marriott — "Infant Nutrition," new edi-

tion, price 5.00

□ Blair — "Cancer of the Face," price... 10.00

n Clark — "Positioning in Radiography,"

price 28.00

n Herrmann — "Heart," price 5.00

□ Willins — "Mayo-Cordiac Clinics." price 5.00

□ Porter-Carter — "Pediatrics," new edi-

tion, price 10.00

Dr

Street

City State

A SHORT SKETCH OF HENEAGE GIBBES
By an old Friend

After reading a reprint of a paper on tuberculosis
that appeared in The Journal, I was reminded of
several incidents of my meetings with this really re-
markable man, Heneage Gibbes.

His life, mannerisms, training and teaching presented
a mixture of London Cockney and Aberdeen stubborn-
ness which we of Aberdonian blood can swear is an
awful combination.

Doctor Gibbes was born in Somerset, England, the
son of a minister and grandson of a noted physician
who had been physician to Queen Charlotte.

Mr. Gibbes decided that his son should study for
the ministry but the young man rebelled and at fourteen
set sail on a vessel bound for the East Indies. He
was captain of the ship at the age of twenty-one.

His stories of his early life were interesting to me
and intriguing. His ship was .involved in the Opium
War between the British and Orientals. Very valuable
cargoes of the pearl fishermen had to be protected on
his ship from many pirates. Shipwrecks were not un-
common and on one occasion Captain Gibbes was
stranded along the Chinese coast on a pirate island but
managed to escape. Once he decided to fight it out
with a pirate ship. The Captain was fond of hunting
and a good shot so he had his Coolie sailors reload the
two guns and took particular pains to get the -wheelman
of the pirate ship — ^and the wheelman was a very neces-
sary adjunct to any ship.

He finally returned home, finished his preliminary
studies from private tutors, and in 1879 he received
his M.B. and C.M. from the University of Aberdeen.
Shortly afterwards he received his F.R.C.P. in London.

Doctor Gibbes became Curator of the Anatomical
Museum of King’s College and also served on hospital
staffs. He had been a student of Dr. Klein, and being
well qualified as a histologist. Dr. Klein and he were
sent to the British Government to make a study of
Asiatic Cholera in 1884.

I had the fortune to take a special course in Patholog\’
from him and he was a fine teacher. Pathology was a
comparatively new subject and here was a man who
claimed much for it. To test him out some wags from
Ann Arbor and Detroit concocted a scheme and sent
him a tissue specimen from a pig’s tail requesting a
report. Lo and Behold ! in a few days the unexpected
report came to hand with the notation, “It is animal
tissue, and not pathological, and it is from an extremity.”
Did he know his patholog>% and how he did his “tail”
unfold.

For a number of years Dr. Ernest L. Shurly and Dr.
Gibbes made exhaustive studies of tuberculosis as the
older journals of the state medical society vdll show.

At one time Dr. Gibbes wrote several articles for a
Chicago medical journal but I am unable to trace the
name of the journal. One of the papers on dro\\ning
told how it feels to go down for a third time as he
had on two occasions.

Shortly before the death of Doctor Gibbes, I spent
a very pleasant afternoon with him in his home at
McAllister, Oklahoma, and it was only then I learned
that beneath a Scottish-Cockney exterior was a charm-
ing character, subdued, cultured, sympathetic, com-
panionable and inspiring. I looked forwnrd to other
visits with the Doctor, but a short time after my first
visit the Doctor passed away.

He died in July, 1912.

If you want a really manly man

Try an honest, cultured, rugged man

With a heart of gold beneath his ribs.

For such a man was Heneage Gibbes.

Weelum

William Fowler, M.D., F.A.C.S.

JouF. M.S.M.S.

678

Tk: JOURNAL

of the Michigan State Medical Society

' Issued Monthly Under the Direction of the Council

Volume 40

September, 1941

Number 9

Planned Farenthnnd

Its Contribution to National
Preparedness*

By Richard N. Pierson, M.D.
New York City

Richard N. Pierson, M.D.

A.B., Princeton University; M.D'.,
College of Physicians and Surgeons,
Columbia University, 1918; Formerly
Attending Gynecologist and Obstetrician,
The Sloane Hospital for Women, New
York. Fellow, American College of
Surgeons, New York Obstetric Society.
Consulting Gynecologist and Obstetri-
cian, Stamford Hospital, Stamford,
Conn., and Huntington Hospital, Hunt-
ington, L. I.

" At a time when world revolution and world

domination by dictatorship threatens, the
American nation may well be concerned with its
resources for defense — material and human. But
thus far the principal emphasis has been put
upon guns, tanks, aircraft and battleships. Now
leaders throughout the nation are beginning to
give thought to our human resources.

“A falling birth rate . . “Race suicide . .

“A nation of old people.” Phrases, such as these,
appearing in news columns, editorials and maga-
zine articles are attracting wide public attention
and arousing public fear.

The people of this nation may well ask
themselves: Are we committing race suicide?
Are we strong enough in numbers and in qual-
ity to defend our democratic institutions?

Much has already been undertaken through the
efforts of the Federal government, to safeguard

*Presented at the 75th Annual Meeting of the Michigan State
Medical Society, Detroit, September 25, 1940.

September, 1941

the national health, to provide security for old
age and for the unemployed, to expand facilities
for public education of children and of adults,
to conserve natural resources and to provide ade-
quate housing for low-income group families. In
this hour of danger, all these things which give
meaning to the word democracy must be co-
ordinated into one great national effort to mo-
bilize this nation’s human resources.

The Nation’s Manpower

In the face of the death struggle in Europe
and in Asia between democracies and totalitarian
powers, the American people want to know :

What is the state of the nation’s manpower?

How will our national strength be affected by
trends in the birth rate ?

The population of North America even dis-
counting the heavy tide of immigration, has in-
creased in 150 years at the most phenomenal rate
recorded in world history. Between 1790 and
1815, the population doubled. It doubled again
between 1815 and 1840; a third time from 1840
to 1865 ; again a fourth time from 1865 to 1900.
If this rate had continued, the United States
would have more than 150,000,000 people today,
instead of 131,000,000, and by the end of the
century, “Our population would have greatly
outnumbered the Chinese.”^

Fortunately for the orderly growth of the na-
tion this extraordinary rate did not continue.
Rapid industrialization and urbanization of the
people, coupled with the economic depression, has
resulted in a marked slowing down of the rate
of increase, saving us from the disastrous con-
sequences that have accompanied unlimited re-
production in other countries — notably China and
India.

Population authorities have built up most care-
ful estimates of our future population growth.

- 691

PLANNED PARENTHOOD— PIERSON

A conservative estimate by two outstanding
authorities (Mf. P. K. Whelpton and Mr. War-
ren S. Thompson, co-authors of “Population
Trends in the United States”) forecasts an in-
crease of nearly 23,000,000 by 1985, when the
total population of the nation is expected to reach
its maximum of 154,000,000. And their esti-
mate includes calculations which anticipate a
further decline in the birth rate of nearly 25 per
cent.

As far as available manpower is concerned
the United States today has approximately 24
million men between the ages of twenty and
forty-five, usually considered the military age
group. (Draft age, twenty-one to thirty-five).
This is four million more than we had during
the World War. And by 1980 it is estimated the
United States will have 26,380,000 men in this
age group.^

Thus, America’s population is increasing and
will continue to increase, according to most reli-
able estimates, for the next thirty to fifty years.
At that time it will reach a maximum peak and
will either riemain stationary or decline slowly.
This trend is reflected in the experiences of vir-
tually every other civilized nation.

The nation’s manpower, both in effective mili-
tary age groups and in productive workers, is
adequate for national defense in point of num-
bers. Thus, it is clear that the cry “race suicide”
with which some have greeted our declining rate
of growth is unjustified by the facts. The rate
is declining. Our numbers continue to increase.

t , ‘ ■

Wasted Resources

The White House Conference on Children in
a Democracy reported in 1940 that between six
and eight million children were in families de-
pendent for food and shelter on various forms of
economic aid. Coupled with that is the fact that
approximately fifty per cent of the 2,000,000
children born in the country each year are born
to families O'n relief or with incomes of less than
$1,000 per year.

Can there be any question that this unbalanced
rate of birth is vastly complicating the social,
health and economic problems of the nation; and
seriously impeding the growth of a sturdy, self-
reliant people, ready and willing to face the ex-
treme emergency of national defense?

f n ' a recent publication, “Our National Re-

692' '

sources,” the National Resources Planning Board,
Washington, D. C., July 29, 1940, reported:

“Preventive health services for the nation as a whole
are insufficient. Hospital and other institutional facili-
ties are inadequate in many communities, especially in
rural areas, and financial support for hospital care and
professional services in hospitals is not enough, particu-
larly for people of the lower income brackets.”

It continued :

“A third of the population, those with incomes under
$750 per year, is receiving inadequate or no medical
service. An even larger section of the population suf-
fers from economic burdens created by illness.”

This inadequacy of the nation’s health re-
sources has a staggering effect on the future
quality of the population. Here are the shocking
facts as disclosed at the White House Confer-
ence :

Among America’s children today :

Six million are improperly nourished.

A million have weak or damaged hearts.

Three millions have impaired hearing.

A million have defective speech.

850.000 are definitely feeble-minded.

300.000 are crippled.

400.000 are tuberculous.

50.000 are partially blind.

This would indicate that we are breeding manv
of our children today under conditions which
predispose to a life of ill-health, permanent dis-
ability, poverty and delinquency. Draft experi-
ences in the Great War showed a disquieting per-
centage of young men physically unfit for mili-
tary service. Physical requirements for the 1940
draft have been lowered.

In study after study, sociologists and authori-
ties in the field of crime and delinquency have
shown a correlation between large, underprivi-
leged families and the incidence of crime.

The crime problem today in America is a
youth problem. As J. Edgar Hoover, director
of the Federal Bureau of Investigation, said
recently, “It is not pleasant to face the fact
that 12 per cent of all murderers, 45 per cent
of all burglars, 32 per cent of all thieves, 13
per cent of all arsonists, and 52 per cent of all
automobile thieves arrested are below voting
age.” The cost of crime is estimated at fifteen
billion dollars a year.

Jour. M.S.M.S.

PLANNED PARENTHOOD— PIERSON

In other ways the nation is paying a high
price for its unbalanced birth rate and for lack
of a positive democratic population policy.

We are estimated to be spending five billion
dollars a year for the relief of dependent indi-
viduals and families ; for the maintenance of in-
stitutions for the insane and the feeble-minded ;
for the care of the aged, the crippled and the
blind.

The cost of ill-health and premature death is
estimated at ten billions ; the cost of social inade-
qtiacy, at five billion dollars a year. The total,
allowing for possible over-lapping, is said to
come to one-fourth of the national income.

But more serious to the future prosperity and
well-being of the nation than this huge annual
toll of economic loss, is the wastage in human
resources upon which the nation must depend for
its future citizens and its future leaders.

American families, many millions of them, be-
cause of ignorance year after year breed more
children than they can care for — more children
whose only expectation for the future is to per-
petuate the conditions of poverty and ill-health
under which their parents live.

The consequence must be of concern to eveiy'^
citizen who has any deep interest in the present
welfare and defense of the nation.

Prosperity and Population Trends

It has been the custom for many business men
and economists to view with alarm the falling
birth rate in the United States, on the basis of
the belief that rapid increases in population go
hand in hand with rapidly expanding economic
growth. In a bulletin on population trends pub-
lished by Standard Statistics Company it was
stated ;

“If the addition of workers to a new country helps
to raise the per capita income through better ex-
ploitation of natural resources, while overcrowding re-
sults in poverty and starvation, there obviously must
be an optimum number of people somewhere between
the two extremes. As the population increases, the
average amount of natural resources per individual
falls. It certainly would be economically unwise to
increase the labor supply past the point where pro-
ductivity per worker reaches a maximum.”

Whelpton stated recently ;

“If this nation could choose bet-ween having a sta-
tionary population of 131,000,000 (our present size) or

September, 1941

150,000,000 or 100,000,000 it can be shown quite con-
clusively that the smaller number would be best from
an economic standpoint.”®

As the Standard Statistics Study has pointed
out, the root of the economic problem arising
from population trends is the relationship be-
tween numbers of people and land and natural
resources. The latter are definitely limited;
there is no readily definable limit to size to which
a population may grow under favorable condi-
tions. And as Professor Henry Pratt Fairchild
has pointed out : “. . . without new land and
augmented natural resources, technology alone
cannot provide for an indefinite increase of
population.”^

“A concrete illustration of the possibilities is furnish-
ed by the record of two brothers, who married two
sisters in Lille, France, in 1830. One hundred and
three years later these two couples had 835 living
descendants.”^

The effect of population trends upon the reser-
voir of productive workers is well-marked. In
1930, 55.5 per cent of the population was in the
productive age group of from twenty to sixty-five
years of age; this percentage, according to con-
servative estimates, should increase to 61 per cent
by 1950. By 1980 the percentage will be approxi-
mately 60 per cent of the total population.® In
consequence it is readily apparent that the eco-
nomic structure of the United States will not
lack for productive man-power as a result of
decreasing population growth.

In 1935-1936 the average annual income of the
American family amounted to $1,622; one-third
of the American families received an annual in-
come of less than $780, the middle third received
from $780 to $1,450, and the highest third re-
ceived $1,450 or more.

E. J. Coll, Director of the National Economic
and Social Planning Association, has strikingly
characterized this problem :

“In the depressed areas of the country are perhaps
40,000,000 people living at, and below, a subsistence
level, and taking a very meager part in the economic
life of the nation. If these people could be brought
into effective production and consumption, total econom-
ic” activity of the nation would be vastly expanded
without any actual increase in numbers of people.”*''- '

60-.1 •

PLANNED PARENTHOOD— PIERSON

America’s Population Problem

It has been the purpose of my observations
thus far to develop the facts as we know them
concerning population trends in this country and
the possible effects of those trends upon the na-
tion’s social and economic life. It seems clear
that America’s population problem today is not
one of numbers, but a problem of qualitative
growth.

Quality vs. Quantity

In numbers the American nation is strong and
will grow stronger. In health and in morale
there is reason to ask the question: Is the quality
of our people in real balance with quantity? Ten
years of harsh economic circumstance for a large
section of the American people have left a resi-
due of social, economic and health problems
which menance seriously the quality of our hu-
man resources, the endurance of democratic
government, and therefore our military defences.

Today America’s population is being bred
from the bottom up. The poorest families,
through ignorance, have more children than they
can afford to rear properly. Families in the
middle and upper income groups, particularly
those in urban centers, are not having sufficient
children to replace themselves, because of eco-
nomic and social conditions which make the bear-
ing of children destructive to the family’s hard-
won standards of living.

This is unbalance.

A Democratic Population Policy

State subsidies, bachelor taxes, medals for pro-
lific mothers — these the totalitarian states have
tried in their drive to breed more and more can-
non (fodder. In large degree they have failed.
Sweden is the one country which appears to
have succeeded : They plan parenthood and sub-
sidize it.

It is an inescapable fact that where conditions
are favorable to early marriage, where the eco-
nomic burden of parenthood may be undertaken
more easily, and where more hope exists for a
better world tomorrow for today’s children, the
people of any nation will bear children and in-
crease or maintain their numbers. Doctors
know that American women continue to want
children.

If the United States is to correct its unbalanced
birth rate; if it is to encourage parents in the
middle and higher income classes to bear more
children; if it is to maintain its population well
balanced in quantity and quality, it must seek
to create these conditions.

♦ * *

SWEDEN’S POPULATION POLICY

By Alva Myrdal, Birth Control Review,

April, 1939

After stock had been taken of demographic changes
and their causes and also of social conditions, a popula-
tion program was formulated, with concrete plans
drafted in seventeen reports by the Population Com-
mission and some ten reports by other related Royal
Commissions. The first proposed reforms were enacted
in 1935, most of the new legal provisions went into
effect January 1, 1938, and some are still only plans,
though thoroughly prepared and officially recommended.
The basic principles of this population policy may be
summarized in three statements, all of which are ap-
parent paradoxes :

1. Voluntary parenthood and a positive population
policy shall be brought together. The neo-AIalthusians
focused their interest on the former, while population
conservatives have centered around the latter. There
is, however, no reason for such a choice. Voluntary
parenthood should be assured, so that the size of in-
dividual families may be regulated according to their
best interest, but community means should be mobilized
so as not to force that regulation to extremes. Only
children welcome to their parents are wanted by the
nation. Birth control must be spread effectively to all
groups of society, in order that only desired children
are born, but at the same time social conditions must
be so rearranged that more children can be welcomed.

2. Both quantitative and qualitative aspects are con-
sidered. The quantitative goal has been fixed at re-
taining, if possible, a constant population ; increasing
population numbers being considered neither feasible
nor desirable. This quota should not, however, be
filled by children undesired by their parents ; quantity
(Should not be secured by sacrificing quality. Thus
Sweden cannot resort to paying premiums to parents
per newborn child, however effective such measures
may be from the purely quantitative interest. All
measures should be shaped so as to insure both the
best improvement in health and environmental con-
ditions for the children themselves and a reduction of
the economic motive for extreme family regulation.
It follows that practical aid, instead of being paid in
cash to parents, should be paid in services to children,
offering rational cooperative consumption, tax-paid for
children of all social groups.

3. The means for a democratic' population policy
must include both educational influences and social re-

694

Jour. M.S.M.S.

PLANNED PARENTHOOD— PIERSON

forms. Sheer moralization and exhortations of duty
to the nation are considered futile. Psychological at-
titudes may, however, be changed by education to
greater understanding of family values and greater
capacity for living in family relations. On the other
hand, economic reforms are necessary by which a
larger share of the national resources are allotted to
children.

Without education, no family reforms can be voted
by a people among whom childless individuals and
“child poor” families already form the overwhelming
majority. Without social reforms no sermons on the
value of larger families can be given to the broad
masses of the people. When the “normal” size of the
family in the majority of non-sterile marriages has
to be fixed at four children in order to keep population
constant in the long run, it becomes apparent that
nine-tenths of the population cannot rear these chil-
dren according to approved standards of health and
culture without considerable community support.

All the positive reforms aim at improving health,
education and environmental conditions in general. To-
gether they form a new system of prophylactic social
policy, safeguarding the quality of the population in
advance and not merely palliating its ills. Such a policy
is considered an investment in the personal capital of
the country, equally as profitable or more so than in-
vestment in factories and machines and other property
which “rust can corrupt and moth consume.”

Basic to any population program founded on
democratic ideals and ways of living is the prop-
osition that parenthood must be voluntary. It
is part and parcel of the democratic ideal, ex-
pressing as it does the right of a child to be well-
born and well-reared; the right of the parents to
undertake the responsibilities of parenthood con-
sciously and in full knowledge of their duty to
themselves, to the child and to the nation. Main-
tenance of a nation’s birth rate by undesired
births not only violates the spirit of democratic
society, but creates social and economic problems
which menace the orderly growth of democratic
institutions, and may lead to the destruction of
democratic government.

To maintain a democratic society, population
replacement would surely better come from
thoughtful and responsible parents, rather than
improvident irresponsibles. It will be generally
agreed that planned parenthood has an essential
place in a comprehensive population program.

As a weapon in the armamentarium of phy-
|| sicians and public health officers, planned parent-
fy hood reduces maternal and infant mortality and
j helps to promote the generaf health of the com-
munity. Specifically it will greatly reduce ma-

ternal mortality by preventing pregnancy in poor
maternity risks ( cardio-vascular, chronic kidney,
et centera) and in women who would otherwise
resort to induced abortions.^.

As a means of promoting marital happiness,
planned parenthood strengthens the family and
promotes the vitality of family life upon which
rests the welfare of the nation as a whole.

In consequence, one of the major tasks of a
sound population program is the rapid extension
of planned parenthood to all families in the
United States who desire it. This would require
not only contraceptive advice available from and
prescribed by physicians, but also the inclusion of
contraceptive advice in state and federal public
health services — a step approved now by seventy-
seven per cent of the American people, according
to a recent Gallup Poll. Already three states
have incorporated birth control into their state
maternal and child health programs, as a very
important health service, which now offer excep-
tional opportunity for study of the benefits that
result from the extension of contraceptive facil-
ities to the poorer sections of the population.

The prevention by sterilization of breeding of
the feeble-minded, the criminal insane, and the
congenitally diseased is a specialized problem
in which progress is being made. Many con-
servative authorities feel that it is full of un-
explored dangers. Most doctors feel that it has
a place which remains to be worked out.

Present activities of the federal, state, and
local governments in the fields of health and
social welfare, if administered with due recogni-
tion of the need for promoting planned parent-
hood, can contribute immeasurably to sound pop-
ulation growth and to the improvement of the
quality of the nation’s people. General education
on maternal and child welfare, with proper em-
phasis on child-spacing and public health services
for those who cannot afford the services of pri-
vate physicians, would reduce the economic
burden of having and caring for children and
promote a more intelligent and conscientious at-
titude toward parenthood.

Corollary to these activities and of equal im-
portance to a national population program is the
need for regional and national planning and
study of the relationship of resources and popu-
lation in various geographic ai’eas. In recent
years, many states and a number of regional

September, 1941

695

PRIMARY CARCINOMA OF THE SCROTUM— ALCORN

planning commissions have been created for that
purpose. Aided by such national bodies as the
National Planning Board, these at present con-
stitute one means of attacking the complex prob-
lems of migration, wastage of resources and
other problems of regional development which
bear directly upon the whole national problem
of population.

An Initial Step

Full development of a comprehensive popula-
tion program in accordance with the American
way of doing things is a complex and long-time
task. Like many another movement devoted to
the national welfare, no ready answer or quick
solution is possible. But the issue is far too im-
portant to be dismissed as too complex to admit
of practical accomplishment. A start must be
made.

A Task for All

America’s population problem is not alone the
concern of students and authorities in the field.
It is the vital and immediate concern of every
citizen of the nation. Practical action upon it
requires the backing of informed public opinion.

Many of the activities now going forward
which bear upon our population problem have the
support of a majority of Americans. But on the
whole problem of population there is little public
understanding of the issues or the possible aven-
ues of attack. One thing is certain : if public mis-
understanding and lack of knowledge is permit-
ted to continue, fostered by cries of “race suicide”
and a “falling birth rate,” public demand may
force ill-considered and ineffective remedies in
the near future, as it has done in the past. Par-
ticularly, effort should be made to resolve the
relatively small remaining controversy between
the Catholic clergy and the majority of the
American people on the subject of the method of
birth control.

Summary

Most Americans believe that the industrial end
of national defense can be well handled by our
industrialists in cooperation with the govern-
ment. Planning and controlling parenthood is
an essential democratic method of developing
and maintaining the optimum quality and quan-
tity of our people. In this planning, we doctors,
we citizens, are confronting a problem of fun-

damental importance to us, and to our children
and to our country, because it determines the
man-power needed for national defense.

Bibliography

1. Fairchild, Henry Pratt: When the population levels off.
Harper’s Magazine, May, 1938.

2. National Resources Committee: Report, May, 1938.

3. Population Reference Bureau, Washington, D. C. Chang-
ing age composition of the American people. Population
Bulletin, March, 1940.

4. Thompson: The Problems of a Changing Population. Na-

tional Resources Committee, May, 1938.

5. Warner: Jour. A.M.A., July 27, 1940.

6. Whelpton, P. K. : Population policy for the United States.
Speech at the National Conference of Social Work, Buffalo,
New York, June, 1939.

MSMS

Primary Carcinoma of the
Scrotum

Report of a Cose

Kent Alcorn, B.S., M.S., M.D.

Bay City, Michigan

Kent A. Alcorn, M.D.

B.S. and M.D., University of Illinois, 1930.

MS. in Urology University of Minnesota
(Mayo Clinic), 1937. Member, Detroit Uro-
logical Society, American Urological Associa-
tion, Michigan State Medical Society.

■ Primary carcinoma of the scrotum is a rare
neoplasm in the United States. The cases re-
ported in this country have occurred chiefly in
New England. According to the literature re-
viewed, no cases have been described as originat-
ing in Michigan, and it is for this reason that the
following case report is of interest.

W. W., a white man, aged 59, presented himself for
treatment in July, 1939. He was bom in an adjacent
county, and had been employed as a fisherman on the
Great Lakes for forty years. His past medical history
contained no record of important illnesses. There were
no references to cancer, tuberculosis, or other consti-
tutional diseases in his family history. Some years ago,
in his occupation, he followed the common practice of
using tar as a preservative for fish nets. However, an
entirely different substance was substituted about ten
years ago. The patient did not recall that his clothing
covering the external genitalia ever became contami-
nated with the tar, although he admitted the possi-
bility. His complaint at the moment consisted of an
ulcerated area on the scrotum. This was first noticed
in November, 1938, appearing then as a small indu-
rated area. In the 2 months immediately preceding his
initial examination, it had grown quite rapidly, with an
increase in localized tenderness. About 1 month before
he was first seen, the involved area became ulcerated.
His weight had remained constant.

The physical examination disclosed a tall slender

Tour, M.S.M.S.

696

PRIMARY CARCINOMA OF THE SCROTUM— ALCORN

man whose appearance belied his age. His left pupil
was slightly larger than the right, and did not react to
light quite as vigorously as the right pupil. The dis-
turbing lesion was located on the inferior portion of
the left scrotum, measuring about 2 cm. by 1.5 cm. It
was freely movable, and appeared to involve only the
skin. The edges were quite firm and somewhat rolled.
Ulceration of the growth had resulted in a purulent
coating, moderate in amount. The scrotal contents
were normal upon palpation. Both inguinal areas con-
tained small palpable lymph nodes. The prostate was
of normal size on rectal examination.

The blood count and hemoglobin estimation were
within normal limits. The blood urea level was 33 mg.
per cent, and the Kahn test was negative.

Clinical Diagnosis. — Carcinoma of the scrotum, wdth
probable metastases.

Under spinal anesthesia, the scrotal lesion was widely
incised. Ample scrotal tissue was available for closure
without tension. Through bilateral inguinal incisions,
the superficial and deep lymph nodes were dissected
and removed.

The scrotal incision healed promptly. From the in-
guinal wounds, there "was a moderate amount of serous
drainage which persisted for ten days before healing
was complete.

Pathological report (Dr. C. M. Ovoen). — Microscopi-
cally, the scrotal tissue exhibited a new growth of
atypical squamous cells, which showed from 25 to 50
per cent undifferentiation. Some keratin was present
with the formation of small pearls. A number of mi-
totic figures and large nucleoli were seen. Consider-
able secondary infection was also evident. The hanph
nodes showed infection, but no metastases.

Diagnosis. — Squamous cell carcinoma of the skin,
grade ii, with an associated infection. Lymphadenitis.

Progress

January 16, 1940. — Patient states that he has been
working regularly, and is feeling well.

September 4, 1940. — K more recent communication
from the patient states that he was seen by his ^doctor,
and the groin and scrotal wounds were found to be
free from palpable masses. The patient is continuing
at his work.

Most of the reported cases in the world litera-
ture of carcinoma of the scrotum have occurred
in the British Isles, where it was noted by Butlin
over 45 years ago as a comparatively common
occupational epithelioma. According to Green, it
was first described by Percival Pott in 1775, and
called “chimney-sweep’s disease.” The number
of fatal cases of cancer of the scrotum reported
by Henry to have occurred in England and
Wales between 1911 and 1935 was 1,487. A
large number of these were in individuals em-

ployed in the cotton-spinning industry. Others
were tar and petroleum workers, and those en-
gaged in the Scottish shale oil industry. The
rarity of this lesion on the Continent in compari-
son to the numbers seen in English hospitals was

Fig. 1.

noted by Butlin many years ago. The subject
was reviewed in this country by Green in 1910,
who found only seven cases in the records of the
Massachusetts General Hospital in the 25 years
preceding 1910. Only four of these were unques-
tionably primary carcinoma of the scrotum; one
was secondary to cancer of the penis, and two
were probably cancer of the scrotum, but were
not verified microscopically. Green also stated
that three of the four proven cases had the lesion
on the left side of the scrotum; two of the pa-
tients had been “mule-spinners” in the cotton
mills of England; the other two were from Ire-
land, occupations irrelevant. Recently, Graves
reported a series of fourteen cases, of which
number, nine gave a definite history of exposure
to oil; of these, three were employed as “mule-
spinners.” Metastases were found in the ingui-
nal glands of ten of the fourteen cases. The ma-
lignancies were grade i in six cases, grade ii in

September, 1941

697

TWENTY-FIVE YEARS OF SERVICE— EULER

four cases, and grade iii in two cases, two cases
being unreported.

Experimental and clinical observations indi-
cate that the mineral oil used in the cotton-spin-
ning industry is carcinogenic, according to Ir-
vine. Leitch has demonstrated experimentally
that certain refined mineral oils used for machine
lubrication are capable of producing carcinoma
of the skin. Of the cases reported in the British
literature, a large number involve individuals in
direct contact with mineral oil. Mule-spinners
work astride a revolving shaft which throws oil
onto the clothing, particularly that covering the
external genitalia. The rotation of the shaft
probably accounts for the predominance of the
lesions on the left side of the scrotum in these
workers.

In the case here reported no co-existing fac-
tors were apparent in the history to account for
the malignancy on the basis of the usual history
given in these cases. This patient had never
been out of the state, and stated that he had had
practically no contact with mineral oils.

Summary

A case of primary carcinoma of the scrotum in
a native-born American is reported, with no
traceable etiological factors, except for the pos-
sible factor of tar, as formerly used in his occu-
pation.

A brief review of the available literature on
primary carcinoma of the scrotum is given.

But few cases have been reported in the Amer-
ican literature. Practically all the cases reported
have occurred in the British Isles, chiefly among
the cotton-mill workers.

Lubricating oil with carcinogenic properties is
believed to be responsible for the incidence
among these workers.

MSMS--

An Expressed or Implied Contract

There exists between the physician and his pa-
tient a relationship resting upon a contract which
is either expressed or implied, and, in practically
all cases, implied. This contract places upon the
physician certain responsibilities and duties, and
a breach of it leading to a bad result or injury
to the patient may be the basis of an action for
malpractice.

Samuel Wright Donaldson, A.B., M.D., F.A.C.R. The
Roentgenologist in Court. Charles C. Thomas, 1937.

698

The Highlights of Twenty-five
Years of Service*

By Marjorie Euler
Topeka, Kansas

Marjorie Euler

" I PROPOSE to discuss, very briefly and very
crudely, a few angles that relate to the run-
ning of a doctor’s office, with the hope that the
discussion may be of some small help to other
medical assistants. The organization of Medi-
cal Assistants is so new that, outside of a few
articles in a business magazine, I was unable to
find anything written concerning their duties, so
I have only my own experience over a period
of twenty-five years from which to draw.

The girl who works for a doctor today en-
ters upon a real career and, it seems to me, one
of the most useful careers that it is possible for
her to fulfill. She is required to take medical
dictation, write case and operative histories, keep
accurate files, handle the doctor’s correspondence,
as well as to act as hostess, nurse, mother, en-
tertainer, telephone operator, bookkeeper, collec-
tor, treasurer, income tax computer and house-
keeper. It seems to me the best type of training
to prepare oneself as a doctor’s assistant, would
be a general business course, including, of course,
shorthand and typewriting and any sort of nurs-
es’ training you could get. I personally do
not think it is necessary to be a graduate nurse,
however, I do think this would help. You can
pick up some of the laboratory work such as
doing urinalyses and blood counts as you go
along. This, of course, makes you more valua-
ble to your doctor, but should contact with sick-
ness and its attendant misfortunes be distasteful
to you or make you worried or depressed, it

*Presented at the Conference of ^Medical Assistants at the
seventy-fifth meeting of the Michigan State Medical Society,
September 24, 1940.

Jour. M.S.M.S.

TWENTY-FIVE YEARS OF SERVICE— EULER

would be much better for you to start your career
in some business office, but on the other hand, if
you have the urge to help and comfort, then
you have found the groove to which you are
best suited, and as the years go on and you get
more acquainted with your work and grow to
love it, you’ll feel like you have been a little
help to humanity and it will be a source of satis-
faction to you.

By being in a doctor’s office you miss one
thing that you will find in a corporation, that is
a chance for a higher position, for there is only
one over you, the doctor, and his place you can
never fill, but within your position itself there
is the possibility of infinite expansion. You
can continue to improve from day to day by
doing splendid and worth-while work and by
making yourself indispensable to your doctor.
In other words be his left hand if you can’t be
his right, and be the best “Girl Friday” you can,
and as you increase in helpfulness, and as his
practice grows, and especially as you learn to
handle his collections efficiently and actually save
money for him, learn to do minor dressings and
relieve him of giving shots, your salary will
grow in proportion.

Personalities

We might start now with a typical day at the
office. Whatever time your office opens, be at
least five minutes ahead of time, so that you do
not have to feel rushed. Your time will always be
well filled so a planned day will give you much
more satisfaction and time, than one that is rushed
and muddled. Nothing annoys a doctor more
than not to have you at the office on time. It is
very annoying to him to have a patient phone
him at home or bother him at the hospital with
this remark, “I called your office but nobody
will answer.” You will find just so many people
of this kind so be on hand and do not let it
occur. Yourself should be neat and well
groomed at all times ; uniform and shoes kept
spotless and white, makeup — yes, we should
be as attractive as possible as we are the first
glimpse that the public gets of the office, but this
doesn’t mean brilliantly colored claws for nails.
Have them well manicured (this can be done by
giving a little of your time and with very little
expense), I prefer a light or natural shade of
polish for the office. I do not think there is
anything more out of place in a doctor’s office

than gaudy nails and costume jewelry. Never
be guilty of wearing a dark slip under a white
uniform nor one that is too long.

Office Housekeeping

Now we are at the office, in uniform and
ready to start the day. We must dust first as
everything around a doctor’s office should be
kept as spotless as soap, water and furniture
polish can make it, magazines arranged neatly on
magazine racks or tables, one at each end of the
room if possible so that patients will not have
to reach across another to get a magazine — as
this is always annoying especially so, if you
do not feel well. Do as much of the doctor’s
correspondence as possible before the doctor
comes in, as it is much easier and you are less
apt to make mistakes, if you run your typewriter
when there are no interruptions, also it leaves
you free to help your doctor when he does come
in. Always have your sterilizer on and at a low
boil, so that in general use or any type of emer-
gency it is always ready to sterilize instruments
without delay. At this time take plenty of
time to check all supplies and see that they are
ready for instant use. Post all books if possible
before the doctor arrives, if you post them eveiy"
day, you will find it takes only a short time;
books kept up is a joy and satisfaction to your-
self as well as your doctor. The morning is a
good time to make and sterilize dressings, steri-
lize and powder gloves and check your laundry.
In ordering supplies I have found it best to
stick to one or two good reputable pharmaceu-
tical houses. After they become acquainted with
you they will give you much better service and
if they do not have your product, they will gladly
order it for you and then keep it stocked. A
word might be said at this time about magazines
in a doctor’s office. Do by all means keep them
up-to-date. The old saying, “If you want an
old magazine, go to a doctor’s office,” I am sure
is fast becoming only a saying and not a reality,
so discard all old and torn copies. I think two of
the so-called woman’s magazines are nice, also
a fashion magazine, as there is not a woman
living, young or old, educated or uneducated,
who is not interested in fashions. Then for those
who have only a few minutes to wait, picture
magazines; Hygiea, the health magazine, put out
by the A.M.A., will always have a big following.

September, 1941

699

TWENTY-FIVE YEARS OF SERVICE— EULER

Patients

Before the patients start coming in I find it
helps to have a list of your appointments on
your desk as well as the doctor’s. Look these
over until you are quite familiar with them, as
nothing pleases a patient more than being ad-
dressed by his own name as he enters. If he
is a new patient be very careful about getting
name (spelled correctly), address and telephone
number. If married get husband’s initials and
his place of employment; if a minor child, get
father’s initials. Do not leave this job up to
your doctor as he is often too busy or else he
knows the patient well enough that he hesitates
geting the rest of the information that is essen-
tial for you to keep good records. I cannot stress
this point too strongly, as this is the keynote of
efficient collecting.

Usher patients in as near appointments as
possible, trying not to show any fuss or rush
regardless of how many are waiting. I have
found it helps to save fifteen minutes in the
middle of the afternoon for the patient who per-
sists in coming in without appointment or for
the out-of-town patient that never seems to
think that it is necessary to phone or write for
an appointment. Theoretically, it is unfair to
those who have appointments to “run in” one
without an appointment, yet it sometimes saves
an excellent case for your doctor. If your doc-
tor tries to take patients by appointment, it is
best for you to tactfully say to the one who
doesn’t have an appointment, “Doctor prefers
to take his patients by appointment” and that
you would appreciate their calling for one in
the future so that you can save more time for
them. Tell them, however, that your doctor
will be glad to see them for a few minutes if
they don’t mind waiting or that you will be glad
to make an appointment for them the next day
so that they will not have to wait. If it is not
an emergency case they will usually cooperate.
If another doctor calls up for an appointment,
this must be arranged without hesitation, but
again you must be very tactful not to let the
already waiting patient know that one is being
slipped in ahead of him.

To the shy, frightened, embarrassed patient
you can be of a great deal of help. A word of
encouragement, said in a sympathetic voice while
she is being prepared for the examination, will
often help as well as win you a world of

friends. Also a shy woman will often tell
the office nurse a great deal of valuable in-
formation about herself that she seems too em-
barrassed to tell the doctor. This you can
convey to him in a few words that will help
him a great deal in his diagnosis of the case. In
this way you can be a great deal of help to both
patient and doctor.

A pleasant smile and ready welcome is a
receptionist’s best weapon in handling any
patient. Learn to handle them she must, and
each one differently. If your doctor is late
getting in for his first appointment, even
though you know he is lunching with his best
crony, telling about the big one that got away
or the best camera shot he ever got, above all
things do not let your patient be aware of the
fact that he is taking a few minutes to relax.
My pet expression is, “Doctor has had an extra
busy morning at the hospital,” or “We have had
an emergency and doctor is going to be a little
late.” I find if you ask your patients to help
you out they will cooperate nicely.

The next in line to take up is the doctor’s
friend that calls. He should not be kept wait-
ing if at all possible not to do so. He may
want to discuss a case with your doctor or he
may just want a friendly chat, but in either
case he always has the lead over all patients.
If he sees patients waiting and it is only a
friendly chat, he will not stay long. If it is a
case he wants to discuss, he will make it as
brief as possible, as he is probably in as great
a hurry as your doctor.

Then come the medical book publishers, in-
strument salesmen and detail men. Be es-
pecially nice to these men, as they are not or-
dinary salesmen. In fact if the doctor is not
too rushed he wishes to see them, as he likes
to hear about what is new on the market. If
you can see by your appointments just about
when your doctor will be at leisure, tell them ;
this gives them a chance to go call on another
doctor in the building and come back when
yours is not so busy. They will appreciate
your telling them and gladly cooperate. In con-
trast to this we have the necktie and hosiery
salesmen, real estate men and peddlers of all
sorts ; even though our buildings are marked,
“No peddlers or soliciting allowed.” These you
should never let get to your doctor, his time
is much too valuable to waste on them, nor

700

Jour. M.S.M.S.

TWENTY-FIVE YEARS OF SERVICE— EULER

must you spend any time with them. I cannot
imagine anything more unprofessional than al-
lowing a salesman to spread his wares across
; your desk when you have a room full of
patients. You can smile and be courteous, but
I at the same tell them that your time is not
your, own and that you cannot look at their
( wares during office hours,

! Office Ethics

! “Office ethics” can be called the title of our
next subject, or casual remarks passed in or
I out of the office about your own doctor, an-
) other doctor in the profession or about a
[ patient, because you will be asked, and you must
I have your answer well thought out. For ex-
ample, you are not free to talk miscellaneously
about health and disease. You realize that you
are not a diagnostician as most people think
I you are. You cannot talk because you know too
much, and because you know you are restrained
you must realize that beyond being considerate,
courteous and efficient, you have no business
discussing, even with a patient, his problem
which the medical expert alone must solve. I
heard Mr. S. A. Long give a talk before the
Kansas Medical Assistants at Wichita this
last spring, and I quote, “If I were a medical
man and had in my employ a secretary from
whom, or through whom, the public ever
found out anything about the people who came
to my office, or why they came or where they
went — if I ever discovered one small instance
of betrayal of that professional confidence, that
secretary would be hunting a job and doing it
so quickly that her heels would scarcely touch
the sidewalk.” Never be guilty of calling a
patient over the phone in the hearing of wait-
ing patients and make an appointment for any
kind of treatment that would give the people
within hearing distance of your voice any ink-
ling of what the patient is being treated for.
The simplest way to take care of this is to make
all such phone calls in the morning before
patients arrive or else call from an inner pri-
vate telephone. Another thing, do not leave re-
ports or history charts of patients lying around
on either your desk or the doctor’s desk so
that anyone entering your office might see
them. It would be quite embarrasing to all
concerned to leave a 4 plus Wassermann report
lying on the desk so that any passer-by might

see it. In casual conversation, if you do talk
about your doctor, give him a boost, say some-
thing about his skill and ability, or tell them
of some of the charity work he does (never
mentioning names) so that they will know what
a competent man he is. You will be surprised
how many cases you can throw his way. Then
there is the question of advice about another
doctor. If you cannot say anything good,
“Silence is Golden,” because a slam at one doc-
tor is a slam at the whole medical profession.
My stock phrase for this situation is, “my
opinion isn’t worth very much as I am not well
acquainted with his work.”

Telephone

The most valuable quality you can have as
a secretary is a good telephone voice, as you
have to make it smile, show sympathy and at-
tention, all in the tone of your voice. Ninety
per cent of your patients call you on the tele-
phone one time or another. Almost all first
appointments are made over the phone. Does
your voice, which should be low, yet distinct,
tell the patient that you are her helper and that
you will be glad to be of any service for her
that you can? Many of your telephone calls
will be from people who are scared, worried,
ill or neurotic. A pleasant, understanding voice
usually calms them down until you get the
information necessary to help them.

In answering a doctor’s telephone never say
“hello” or give the telephone number, as most
people forget the number as soon as it is given
or dialed, so it means nothing to them. Answer
by giving the doctor’s name, such as, “Dr.
Smith’s office,” with a raise in your voice as
though you were asking a question, or that you
are willing and waiting to help the person call-
ing. If there are two doctors in the office, say
each name distinctly, with a slight pause in be-
tween, such as. Dr. Smith’s and Dr. Jones’ of-
fice. Your telephone company has worked out
a good many suggestions that, if studied, will
be a gr^at deal of help to most of us in answer-
ing the telephone. If your speech is not so clear
and distinct as it should be, deep breathing
exercises and counting while holding the breath
tend to deepen and strengthen your voice.

Answer your telephone on the first ring if at
all possible. To the person who is calling the
doctor, each second is a minute, so if the phone

September, 1941

701

TWENTY-FIVE YEARS OF SERVICE— EULER

rings five times before it is answered, he feels
that he has waited five minutes for the doctor to
answer. On the other hand the telephone com-
pany will tell you to let the phone ring ten times
when you are calling a number before you con-
clude that the person you are calling is not there.
If you are busy when the phone rings, whether
talking to a patient, writing a receipt, or doing
any other small piece of work, stop immediately
if possible. If you are busy with a patient, say
“Excuse me please,” and then answer your phone,
with no show in your voice that you are hurried
or busy. The telephone company advises that to
make your voice carry most pleasantly and at
the same time clearly, speak directly into the
mouth piece with your lips not more than half
an inch away. Do this in a quiet, unhurried
manner ; no loud talking or shouting is neces-
sary.

The telephone company will also give you a
list of rules for pronouncing numbers and let-
ters. These do not exactly correspond with
your dictionary, but so many names and num-
bers sound alike over the telephone that when
they are pronounced in the way they advise
they are more easily understood. I will give you
a few of them, and if you wish any more I am
sure your telephone company will gladly supply
you with them for the asking. They will also
give you a talk on telephone usage if you will
ask for it.

O — pronounce as if it were spelled oh with a round
and long O.

One — pronounce as if it were spelled wun, with a
strong W and N.

Two — pronounce, too, with a strong T and a long
00 sound.

Three — pronounce th-r-ee, with a slight roll of the
R, and a long EE.

Four — pronounce as fo-wer, two syllables with a
strong F, long O and a strong final R.

Five — pronounce fi-iv, with a long i and a strong V,
and so on.

When you answer the telephone — Dr. Smith’s
office — you will invariably get the remark, “Is
Doctor Smith in?” your reply should be either,
“Yes, doctor is here,” or “No, not at this time.”
If he is in and so he can talk, connect him im-
mediately, after saying, “One moment, please.”
If he is busy and cannot talk, tell them so and
that if they will leave their number you will
have him call them in just a few minutes. Keep
a scratch pad and pencil at each telephone and
one in your pocket, so that you will have one

available for this purpose — do not trust yourself
to remember these messages, because if you get
busy you will forget. If he is not in, ask their
name and telephone number and tell them you
will have the doctor call them as soon as possible.
Again your voice plays a big part in getting the
information that you want. Do not neglect
these telephone calls. If when calling the doc-
tor to tell him about them, you find he is in
surgery or delivering a baby, try to find out
how long he will be and then call back and tell
them — your efforts will be appreciated. Handle
all phone calls that you possibly can yourself,
such as, making appointments, call about col-
lecting, soliciting for office magazines etc. Your
doctor will appreciate your handling these de-
tail.

In closing a conversation on the telephone
simply say “good-by,” never give a vague “all-
right” nor use the slang expression “O. K.”
Do not use the doctor’s telephone for visiting
with your own friends. A long conversation
over the telephone might be the cause of a very
sick patient, or an emergency case that would
mean a good many dollars in your doctor’s
pocket, to go to another physician, or even mean
the life of the patient. Ask yoiir friends not
to call during office hours, unless it is an emer-
gency, then make that as short as possible. If
you are making a call for your doctor, state
in the beginning whose office is calling and
briefly what you want, such as, “This is Dr.
Smith’s office. Dr. Smith would like to speak
to Dr. Jones.” Always when talking on a tele-
phone, take complete command, refrain from
stuttering, mumbling or saying “Ee-um, let’s
see,” or “Listen” ; state your business in a short
concise form and do not be stingy with your
“thank you’s” for any favors.

Insurance Papers

I think a word could be said at this^ time about
the insurance patient. All the papers that are
necessary to make out on the Workmen’s Com-
pensation cases gave me a good many head-
aches, until we had printed cards made es-
pecially for these records. It is a card 8 inches
by 5 inches and is kept in a file separate from
all other records. On this card is a place for
patient’s name and address, firm for which he
works, and the name of the insurance com-
pany that carries the liability. Age, marital

Jour. ^I.S.M.S.

702

TWENTY-FIVE YEARS OF SERVICE— EULER

status and color, place for when first and final
reports were in. History of injury", diag-
nosis and when and who took roentgenograms
i and the report of the x-ray findings. Examina-
I tion of patient. On the back is a place for the
I charges. The first report is sent in as soon as

I possible. This, I can do in the morning with-

I out having to bother doctor with questions, and
I the final report as soon as we have finished

I with the patient. If a careful record is kept,

these cases are very easy to handle and you
I will find that they are the best pay cases you
! have, so are well worth taking care of.

Mail

Taking care of the doctor’s mail can come
under another head. Everyone knows who
works in a doctor’s office, the untold amount
of advertising that the doctor receives. After
you have worked for him a short time you soon
learn which ones he likes to look over and the
ones that hit the wastepaper basket with only
a passing glance. These you can open and dis-
card, the checks you list very carefully, on your
records and also on the deposit slip. All per-
sonal mail should be placed in one pile, in a
convenient place on his desk so that he can
go over it hurriedly when he first comes in.
All insurance reports and requests for histories
from other doctors can be placed in another
pile. To these you should have their histories
looked up and attached to the letters, so that
when your doctor has a leisure moment he can
fill these out with very little trouble. The bills
should be placed in a drawer or special file after
having been checked to see that they are cor-
rect. Then on or before the tenth of every
month all bills should be paid. You can save
the doctor time by writing the checks and plac-
ing them on his desk for his signature. He will
appreciate your looking after these details for
him. As you buy supplies and pay his bills, you
should have a special book, correctly tabulated
for your income tax records. I assure you, this
kept up from day to day and month to month
will save you and your doctor many a head-
ache at the end of the year when this record
has to be made out.

Collections

Now we reach the last but not least of our
troubles, “Collections,” which is to most doctors

September, 1941

the hardest part of their profession. Each of us,
I know, has our own particular theory" of how
we should approach this problem. Everyone
will, however, agree that the primary necessity
is the absolute confidence placed in us. Build-
ing upon this confidence, we must, of course,
vary our program to suit the type of practice
which our doctors enjoy. Thus, a collection pro-
cedure based upon a rural community will differ
radically from that of the urban community.

There will be the necessity of pointing our
collections toward varied “Crop Types,” as
against partial payment system based upon pay
rolls. In any procedure, however, we must re-
member that the work connected with this will
rapidly grow into a Frankenstein and prove
unworkable simply because of the volume of
correspondence which it creates. Therefore, it
has been considered advisable to eliminate, as
much as possible, the personal element in deal-
ing with routine collections. By this classifica-
tion I mean the type of account which becomes,
let us say, sixty to ninety days past due. I
will endeavor to tell you some of the plans we
use, not particularly because I believe that they
are the best, but because they eliminate to a
large extent the amount of personal correspond-
ence required. In the case of the patient which
is to be hospitalized, we immediately fill out a
card which I will call Exhibit No. 1. The in-
formation on the back of this card is not filled
out unless the patient immediately requests
credit accommodations. The husband or the
wife of the patient is contacted and such in-
formation regarding the status of the patient
is obtained from that source. The Credit Bur-
eau, if such is available, is called to ascertain
the paying habits. We have experienced dif-
ficulty at times in obtaining information on
people living in the country some distance from
Topeka. I find however with very little trouble
you can establish sources of information in
various small towns, through the owners of
mercantile stores, banks, etc. These people can
be contacted by phone and any information they
have available is obtained. Through the banks
we can obtain the patient’s attitude toward taking
a loan that will combine the hospital and medical
bill. We find in a great many cases the banker is
already holding papers on the party and by dis-
counting our bill, he is willing to combine them
with the papers he already holds. If a patient is

703

TWENTY-FIVE YEARS OF SERVICE— EULER

willing to borrow the money to pay his bill in full,
we are always willing to discount the bill to the
extent of whatever interest he has to pay to get
the money. In Kansas, the crop mortgage is
good only for the year in which it is written.
Naturally the mercantile company or the bank
is going to take a mortgage, not only for the
crop, but upon the livestock and any other tangi-
ble collateral which the patient may have. Thus,
if, as so often is the case, the amount realized
from the crop is insufficient to pay off the first
mortgage, then the holder of that mortgage is
unable to rewrite his crop lien without sacri-
ficing his priority claim, as the law provides that
the rewriting of such is evidence that the prior
claim has been satisfied. In this way, you will
see that the second mortgage has a very definite
nuisance value.

In regard to the patient who has more or less
steady income, there are two courses open to

us.

1 — To persuade the party to go to the bank
and borrow from them the amount required.
I am sure there are banks in all the larger places
that have a special department for this type of
loan.

2 — To handle them ourselves through a
partial payment plan.

The number two plan sems to be the more
favorable, especially for obstetrics and surgery,
as these generally are the larger types of bills.
Take the obstetrical case and the charge would
be, say $50.00, and you get the case at the
fourth month of pregancy. A payment of ten
dollars a month and your bill is paid by the
time the baby arrives. In the operative case,
the money starts a little later, as my doctor al-
ways tells them to pay the hospital bill first.

Now we come to the third type of procedure,
and to my mind the most bothersome, which
is that of dealing with the ordinary garden
variety of open accounts. On this type of state-
ment we send the bill once a month, sometimes
on the first and sometimes on the 15th. We find
quite often that if sent on the 15th we get more
response than on the first, as they seem to have
so many bills to take care of on the first. After
ninety days, if we get no response, the account
is considered delinquent and routine collection
procedure is inaugurated. For this we have

three letters we send out, one a month for three
months. The first is as follows :

Name —

Address — ■

Amount of bill —

May we call your attention to your account with
us in the above amount. We have sent you several
statements which you may have overlooked. If you
are unable to make prompt payment, kindly let us
know when we can expect your remittance. If you
cannot pay in full now, won’t you please mail us a
check for half, and send us the balance next month?

Please let us hear from you this week, without
fail.

Yours truly,

(Signature)

If we do not get any response, then this let-
ter is sent:

We again call your attention to the past due ac-
count listed above. We do not think it is your in-
tention to evade the payment of your debts, and are
assuming that you, like so many other people, have
taken the mistaken attitude of saying nothing when
you have been unable to pay.

Our doctor did not hesitate to serve you when you
were in need of help. We appeal to your sense of
fairness. Surely you could let us know the circum-
stance and possibly some plan could be worked out
to insure payment of this account and yet work no
hardship on you. You may be assured that we will
go along with you on any reasonable arrangement
you may care to make.

Yours truly,

(Signature)

And the third and last letter :

Our records indicate that we have sent you several
statements and are forced to write you in an effort to
make suitable settlement to this claim. We feel sure
that you have no reason to contest the amount of
these charges and we must look forward to the
immediate payment of same.

It is going to be necessary to turn over to the
Credit Bureau our list of delinquent accounts and we
are sure you do not wish yours to be placed on a
record that will affect your credit wherever you may
SO-

We should regret being forced to do this and we
ask your cooperation in immediate settlement of this
bill.

Yours truly,

(Signature)

Then, of course, if we get no response, the
amount is turned over to our collection agceny
to let them see what can be done. The bill that
is turned over to the collector should be filled
out in complete detail, as so often patients will
dispute a certain item of the bill and if your
collector has the complete information in front
of him, he will be in a position to discuss this
matter intelligently and to make proper adjust-
ments without bothering your doctor.

Obviously, this type of letter is sent only
those we know can pay and won’t. Anyone who

Jour. M.S.M.S.

704

GALL-BLADDER DISEASE— GARIEPY AND DEMPSTER

has ever worked in a doctor’s office knows that
her doctor does an untold amount of work each
year for the low salaried and indigent patients,
for whom a charge is never placed on the books.

MSMS

Gall-Bladder Disease

Surgical Treatment*

L. J. Gariepy, M.D., and J. H. Dempster, M.D.

Detroit, Michigan

Louis J. Gariepy, M.D.

M.D., University of Michigan, 1922. Senior
Surgeon, Mt. Carmel Mercy Hospital; Con-
sultant Surgeon, Wyandotte General^ Hospital,
Wyandotte; Associate, Redford Receiving Hos-
pital; Surgeon of Detroit Medical, Surgical
and Dental Group. Member, Michigan State
Medical Society.

■ The discriminating surgeon who regards the
reputation of his art will carefully select his
operative cases and will confine surgical treat-
ment to such conditions as gallstones, empyema,
hydrops produced by stenosis of the cystic duct,
obstructive jaundice due to stone in the common
duct, or chronic pancreatis due to gallstone or
gall-bladder pressure. Cholecystitis cases not
benefited by dietary and medical treatment nat-
urally belong to the domain of surgery.

Surgical treatment of gall-bladder disease is a
matter of choice with the surgeon and needless
to say it must be made to conform to the condi-
tion present. The surgeon may be a good tech-
nician, a good operator, but if his surgical judg-
ment is not good, his results will be unsatisfac-
tory. ■

The question of removal of the gall bladder
rests entirely with the operator, who must take
into consideration the condition of the patient as
well as the condition of the gall bladder. I have in
many instances drained gall bladders that I felt
at the time should come out, but rather than sub-
ject the patient to greater risk, a drain was in-
serted and the gall bladder removed, in a few
cases, three or four months later. When the ab-
dominal cavity was opened for the secondary op-
eration the gall bladder had almost entirely atro-
phied so that the symptoms of which the patient
complained were evidently due to adhesions
about the common duct.

*Read before the Staff of Mt. Carmel Mercy Hospital, Detroit,
Michigan, Oct. 4, 1940.

Dr. Dempster’s part in the study of gall-bladder disease, the
treatment of which is presented in this paper, consisted in the
x-ray diagnosis of the various cases under consideration.

September, 1941

Any abdominal operation should attain its ob-
ject with as little trauma to the viscera as possi-
ble, to the end that shock may be minimized,
postoperative discomfort reduced, convalescence
shortened and adhesions prevented. With this in
mind, all cases are prepared carefully so that if
at all possible the abdomen may be closed without
drainage. In suggesting as a routine procedure,
the closing of the peritoneal cavity without drain-
age after a cholecystectomy, one departs from the
standard technique to an extent that few sur-
geons would care to follow.

The obvious advantages from closing an ab-
dominal wound without drainage after remov-
al of the gall bladder are :

Few postoperative peritoneal adhesions.

Simple conditions, if necessity for re-opening
arrives.

Simplified after-treatment and more rapid conva-
lescence.

Less discomfort to the patient, no painful removal
of drain.

Less danger of postoperative ventral hernia.

Avoidance of possibility of persistent sinus forma-
tion.

Avoidance of mechanical interference with gastric
function due to pressure on duodenmn, and
partial or complete duodenal obstruction.

Less danger of bile leakage when gauze drain is
used over the cystic stump.

Avoidance of pulmonary infarct, following the
removal of the drain.

Cholecystectomy without drainage shortens the
hospital time so much that the average patient
can be discharged from ten to twelve days fol-
lowing the operation. This factor is also impor-
tant when the finances of the patient are a matter
of consideration.

Technique

In most cases the gall bladder is removed from
above downward. I first aspirate the gall bladder
with a special device which is a suprapubic aspi-
rator pump to which is attached a sterile rubber
tube inserted into a sterile bottle. This tube has a
special fenestrated needle which is used for suc-
tion. The bile enters the bottle and the gall blad-
der is then easily removed from above downward
with very little trauma or shock.

Routine management of the gall-bladder patient
consists in elevating the bed on six inch blocks
after the return from the operating room and
providing him with a pneumonia jacket as well
as a Scultetus binder. Glucose and saline are
given intravenously as a routine and insulin is

705

GALL-BLADDER DISEASE— GARIEPY AND DEMPSTER

given to diabetics. In many instances when post-
operative vomiting is present, a small dose of in-
sulin checks the nausea and vomiting.

Statistical Study

During the four-year period ending August 10,
1940, I have operated on 274 patients with gall-
bladder disease. For convenience of study they
are here tabulated :

TABLE I. DIAGNOSIS

Type

Cases

Eercentage

Chronic cholecystitis

. 229

83.58

Acute cholecystitis

. 22

8.04

Hydrops of gall bladder

. 5

1.82

Empyema of gall bladder

. 9

3.29

Gangrene of gall bladder

. 3

1.09

Ruptured gall bladder

. 1

.36

Cancer of gall bladder

. 3

1.09

Common duct stone

. 2

.73

TABLE II. CHOLECYSTITIS

(Non-Calculus)

No.

Type

of Cases

Percentage

Acute

. 9

3.29

Chronic

. 112

40.88

Empyema

. 3

1.09

Cancer

. 2

.74

Hydrops

. 1

.36

(Calculus)

No.

Type

of Cases

Percentage

Acute

. 13

4.74

Chronic

. 117

42.70

Gangrenous

. 3

1.09

Empyema

. 6

2.19

Cancer

1

.36

Hydrops

. 4

1.46

Common duct stone

2

.74

Ruptured gall bladder

. 1

.36

TABLE III. AGE INCIDENCE

No.

Age

of Cases

Percentage

0-9

.. 0

00

10-19

.. 0

00

20-29

.. 12

4.38

30-39

.. 55

20.08

40-49

.. 99

36.13

50-59

.. 76

27.73

60-69

.. 31

11.32

70-79

.. 1

.36

The youngest male was 21 years ; the youngest
female also 21 years. The oldest male age 58
years and the oldest female age 75 years.

No.

Sex of Cases Percentage

Male 37 13.23

Female 237 86.77

Deaths 8, or 2.92 per cent; 7 females and 1
male.

Glycosuria was found in 28 cases (25 females

and 3 males) of gall bladder pathology, or 10.21
per cent.

Jaundice was found in 29 cases (24 female and
5 male). There was concurrent pathology in the
appendix and an appendectomy because of con-
current pathology in 92 (33.57 per cent) of the
274 cases in conjunction with the gall-bladder
surgery.

There were 65 cases (23.72 per cent) wherein
the liver showed macroscopic pathology, such as
both stages of cirrhosis and multiple cysts.

Concomitant pathology found at the time of
the operation may be listed as follows :

Cancer of the liver — 4 cases

Cancer of the ampulla of vater — -1 case

Cancer of the pancreas — 1 case

Cancer of the cecum — 1 case

Multiple cysts of the liver — 1 case

Peptic ulcer — 3 cases

Sciatica — 2 cases

Coronary thrombosis — 1 case

One typhoid carrier

Acute pancreatitis — 2 cases

Intestinal obstruction from a gallstone following a
ruptured gall bladder — 1 case

Drainage

There were 78 cases in which drains were left
in the gall-bladder fossa. These drains were left
in place for an average of 5.92 days. The short-
est drainage period for this group was 2 days ;
and the longest drainage period, 14 days. There
were 33 cases in which a cholecystotomy was
done. In these cases the drainage tube was left
in place on an average of 9.13 days. The shortest
drainage period was 5 days ; and the longest
drainage period was 16 days.

Cholecystitis and Associated Conditions

Regarding the coincidence of cholecystitis with
other diseases, no exhaustive study has been re-
corded. The association of gall bladder with other
diseases is therefore largely a mater of clinical
impression.

The association of diabetes with cholelithiasis,
where the two conditions are concurrent, is pre-
sumed to be due to damage of the pancreas by
extension of disease from the biliary passages.
It is difficult to prove, says Allen {loc. cit.), that
gallstones cause diabetes ; the conclusion may be
that the diabetes is secondary to the cholelithia-
sis or to other infection of the biliary tract. The
association of diabetes and gallstones, particu-
larly in women over 40 years of age, would war-
rant a search for the other condition when one

706

Tour. M.S.M.S.

EPILEPSY AS A TRAFFIC HAZARD— HIMLER

was found present. In other words, a diabetic
patient past 40 should be examined for gallstones
and the gallstone patient in the same age group
should have frequent urinalyses to determine the
presence of glycosuria. Seeing that pressure of
gallstones on the head of the pancreas may be
associated with diabetes, it is well to check over
all diabetics to ascertain a positive cause of the
disease. Though the percentage of diabetes re-
sulting from gallstones may be small, the search
is worthwhile. In my series of 274 cases which
came to operation over a four-year period, glyco-
suria was found in 28, or a percentage of 10.21.

Cholecystitis is so common especially during
the fourth, fifth and sixth decades of life that its
incidence is only less than vascular and cardiac
disease and diabetes. Operative treatment of
cholecystic disease 'is very frequently followed by
a concurrent improvement in some other coexist-
ent disease. Many surgeons concur in the belief
that such abdominal diseases as chronic hepatitis,
pancreatitis and appendicitis are associated with
gall-bladder disease. No association, however, has
been noted between peptic ulcer and cholecystitis.
Peptic ulcer is apt to be associated with the tall,
narrow chested habitus ; gall-bladder disease with
the broad habitus.

In this series of 274 cases, 92 appendectomies
were performed but I do not wish to leave the
impression that appendicitis is a causative factor
of cholecystitis or vice versa. I can see no neces-
sary connection as in glycosuria and some forms
of cholecystic disease. Many gall-bladder patients
gave a history of symptoms that pointed to a
chronic appendicitis sometime in their lives
which had become quiescent or latent. A number
of patients operated on by me for gall-bladder
disease had also been operated on by other sur-
geons for appendicitis.

Conclusions

Patients operated on for gall-bladder disease of
various types in the four-year period ending Au-
gust 10, 1941, numbered 274. This number con-
stitutes only those instances of gall-bladder dis-
ease which have been treated surgically.

In the matter of diagnosis reliance was placed
on the clinical manifestations, together with x-ray
study by the Graham-Cole method.

Cholecystectomy was the operation of choice.
In a great majority of instances complete closure
of the operative wound following operation was

September, 1941

done. It is believed this practice has a distinct
advantage over that of routine drainage.

The cases have been summarized on the basis
of type of pathology, age and sex incidence and
with regard to associated pathological conditions.
We have found a certain relationship between
some cases of glycosuria and gall-bladder pa-
thology. This relationship warrants examination
of the diabetic patient routinely for gall-bladder
disease and, conversely, studying of each patient
presenting a gall-bladder syndrome for evidence
of a diabetic tendency.

MSMS

Epilepsy as a Traffic Hazard

L. E. Himler, M.D.

Ann Arbor, Michigan

L. E. Himler, M.D.

A.B., University of Michigan, 1928. M.D.,

University of Michigan Medical School, 1931.
Diplomate of American Board of Psychiatry
and Neurology, 1939. Asso'ciate psychiatrist
at the_ University Health Service. Member of:
American Psychiatric Association, National
Committee for Mental Hygiene, Michigan So-
ciety of Neurology and Psychiatry, Internation-
al League Against Epilepsy, and Michigan State
Medical Society.

■ The provisions of practically all of the forty-
five states possessing operators’ license laws
include some type of restriction against individ-
uals who are unfit to drive. Michigan’s Act 91
of 1931, which is patterned after the so-called
“Uniform Motor Vehicle Operators’ and Chauf-
feurs’ License Act,” expressly prohibits licensing
anyone who is “afflicted with or suffering from
such physical or mental disability as will serve
to prevent such person from exercising reason-
able and ordinary control” while operating a mo-
tor vehicle upon the highways. License is also
withheld from any person who has been ad-
judged by the courts to be “insane, or an idiot,
imbecile, epileptic, or feeble-minded” and has not
been restored to competency by judicial decree.
Even then a driver’s license is not granted unless
and until the- department given the responsibility
for issuing licenses is satisfied that the individual
is capable of operating a motor vehicle with safe-
ty to persons and property.

The necessity of uniform and effective meas-
ures aimed at eliminating the danger of epilepsy
in traffic is self-evident when it is recalled that of
the 500,000 or more patients with epilepsy in the
United States, fully 450,000 are not in institu^

707

EPILEPSY AS A TRAFFIC HAZARD— HIMLER

tions but are living in the community. Half of
these have already begun to have attacks by the
time they are old enough to drive cars, and two-
thirds of them have had their first attack before
they reached the age of twenty. Regardless of
licensing restrictions, physicians who make spe-
cial inquiry into this point are well aware that a
considerable proportion of patients with epilepsy
do not refrain entirely from driving motorcars.
Although accidents frorp this cause are not un-
known, up to the present time no statistical evi-
dence is available which would disprove the be-
lief held by both physicians and safety officials
that traffic accidents attributable directly to epi-
lepsy are quite infrequent.

A summary prepared by the National Safety
Council for 1939 reveals that 0.5 per cent of the
drivers involved in fatal accidents and 0.3 per
cent of the drivers in non-fatal accidents had
some physical defect "other than intoxication,
fatigue, poor eyesight and poor hearing.” This
is equivalent to about 200 drivers in fatal acci-
dents and approximately 4,(X)0 drivers in non-
fatal accidents. Epileptic disorders are not re-
ported as such and of course cannot be arbitra-
rily presumed to constitute more than a fraction
of even this restricted group, since under the
same classification are included a variety of mis-
cellaneous physical defects such as would hinder
the use of arms and legs, cerebrovascular and
cardiac conditions, acute uremia, acute acidosis,
vertigo, narcotic poisoning, and sudden painful
conditions which might result in syncope or
temporary loss of control — to mention but a few.

Accident statistics alone, however, can give
only very incomplete information on this sub-
ject, not only because patients who survive an
accident would be disinclined to tell of their
attacks, but more importantly because report-
ing police officials could scarcely be expected
to recognize or distinguish post-seizure states
from such causal conditions as fatigue or fall-
ing asleep. In this connection, one can only
speculate on what proportion of the many acci-
dents reported as “driving on wrong side of
road,” “driving off roadway,” and “reckless
driving” might be related to epileptiform
states.

Some light is thrown on the incidence of epi-
leptic patients who drive motorcars by reports

dealing with traffic offenders. Among 100 un-
selected violators coming before the Detroit Re-
corder’s Court during a single month, there was
one with active epileptiform attacks and one with
suspected epilepsy.® Of 348 offenders referred to
the traffic clinic of the same court during 1937, a
history of epilepsy was obtained in one and a
question of epilepsy occurred in two other cases.®
While the number of cases is too small to have
general statistical validity, it is significant that in
both groups of offenders the proportion with
verified attacks is higher than for epilepsy among
individuals of all ages in the population at large.

Plan for Regulation

Aside from the problem of enforcement, un-
conditional denial of driving privileges to all pa-
tients who have or have had any type of seizure,
although the only completely safe method would
result in manifestly unfair discrimination in
many individual cases. In this category would
fall those with seizures occurring only during
sleep, and those who are certain of a sufficient
warning period to prevent any mishap on the
road. It is especially important to include in
this group those patients who are free of attacks
as long as they continue faithfully under medical
treatment and supervision. What is said with re-
spect to motorcar drivers, of course, applies
equally to airplane pilots and those who operate
motorcycles and bicycles on the highways.

Although methods of examining applicants for
drivers’ licenses vary markedly from state to
state, inquiry concerning the presence or absence
of “epilepsy” is generally designated as part of
the duties of the police official in charge of reg-
istration. Since the term “epilepsy” as used by
the layman is ordinarily restricted to mean con-
vulsive seizures of the grand mal type, it is pos-
sible that some individuals might truthfully an-
swer in the negative to such a routine question,
and yet be afflicted with petit mal, psychomotor,
or narcoleptic attacks which might be equally as
dangerous in traffic as grand mal. The patient
with petit mal seizures lasting over a second or
two may be in even greater peril, since attacks of
this type may occur quite frequently, generally
with no warning, and often are related to sud-
den stress such as might come up in traffic situa-
tions. The writer has had contact with two such
cases during the past year, one of whom reported
numerous “close calls” and the other actually

708

Jour. M.S.M.S.

EPILEPSY AS A TRAFFIC HAZARD— HIMLER

went off the road twice during typical attacks,
yet both of these patients were in possession of
drivers’ licenses, and although aware of the
element of danger, did not consider themselves
as “epileptic.”

Confusion over interpretation of the term
“epilepsy” can be avoided by requiring applicants
to answer a specific written question referable
to the presence of any type of paroxysmal condi-
tion. A composite driver’s license application
blank, proposed by the American Association of
Motor Vehicle Administrators,’^ combines the ex-
perience of several states and includes the fol-
lowing as one of twelve questions ;

Have you ever had an attack of epilepsy, paralysis
or heart trouble, or are you afflicted with fainting or
dizzy spells or any disability or disease which might
affect your ability to operate a motor vehicle in a safe
manner at all times and under all conditions? (Yes or
No). If you have, give date, and describe condition.

Applicants who answer affirmatively are then
required to submit a physician’s statement with
regard to their competency to drive with safety.
In Michigan, patients with epilepsy who have
been free of attacks for at least two years may
be granted or reissued a license after proper in-
vestigation by the Commissioner of the Traffic
Division.

Privileged Communications

The wide variety and complexity of problems
which arise in any consideration of the epileptic
driver inevitably bring up questions relative to
the sanctity of medical confidence and how far
such a patient has the right to be protected by
privileged communications. Dr. Monrad-Krohn,
the Norwegian neurologist, states imhesitatingly
that “in the face of a very real danger, it would
seem that the community has a right to demand
control even if it involves a necessary infraction
of professional secrecy on this point.”^ At the
Eighth Scandinavian Neurological Congress held
in 1939 a unanimous resolution was passed rec-
ommending “that it be in some way established
that it is a duty of practicing physicians without
regard to their obligation of silence, in some way
to notify the authorities, whenever in their prac-
tice they discover a patient suffering from epi-
lepsy in the possession of a driving vehicle and
making use of it.”

An important step toward the solution of this
problem was taken by the state of California,

where in September, 1939, a law became effective
designating epilepsy as a reportable disease.^
Physicians in that state are now required to no-
tify the State Department of Public Health of
all patients with such a diagnosis, and this data
is then made available to the Motor Vehicle De-
partment. Failure of the physician to report con-
stitutes a misdemeanor. In so far as it is possible
to enforce a quarantine law of this type, the li-
censing of at least those patients who come under
physicians’ care because of obvious and undis-
puted grand mal will be effectively barred. How-
ever, because of the unsatisfactory status of the
term “epilepsy,” this regulation as it stands still
allows for confusion and omissions, especially
where seizures are not clearly defined or where
the differential diagnosis is obscure. During the
first six months the California law was in force,
2,780 cases were reported, but only 437 of this
number were from counties not containing insti-
tutions in which epileptic patients were hospi-
talized.

Dr. Monrad-Krohn suggested a plan of an-
other type which would avoid some of the above
objections. This would require the physician by
law to give a statement to all patients who are
subject to paroxysmal disorders regarding their
competency to drive a motor vehicle, a copy of
which is submitted to the traffic officials. This
step, while not placing the burden of a final de-
cision on the physician, nevertheless makes it
obligatory for him to acquaint the patient of the
mutual responsibility which he shares with re-
gard to traffic regulations. Final approval, de-
nial, or restriction of drivers’ license privileges
might properly be vested in a duly authorized
medical examiner, preferably one attached to the
State Health Department. The patient should in
no case be deprived of his right to petition for a
hearing and submit statements relative to his
condition from physicians of his own choice.
While it may be objected that such a plan de-
stroys confidential relationship and may discour-
age some patients from seeking medical aid, it
might on the other hand actually strengthen the
physician-patient relationship in the end, since a
satisfactory period of observation and treatment
opens the way for official recommendation for a
license. Full professional secrecy would of neces-
sity be required from traffic and police author-
ities who share confidential information with
physicians under any such arrangement.

September, 1941

709

PYELOGRAPHY— HUBBELL AND HILDRETH

Method of Control

Whatever ultimate disposition is made of this
complicated problem, it would seem only just
in the interests of both society and the individual
that no patient who is subject to seizures should
be granted a license until proper investigation is
made by a physician trained in neuropsychiatry
who is equipped to make valid judgments con-
cerning an applicant’s fitness as a motorcar driv-
er. Among the special diagnostic procedures
utilized in the study of epilepsy, electroencepha-
lography® has become outstandingly important.
Repeated at regular intervals, the electroenceph-
alogram gives an objective record which is in-
valuable both in substantiating the diagnosis and
in providing an index of the effectiveness of
treatment.

The medical, neurological and psychiatric ap-
praisal of each case should include a satisfactory
control period of observation as a basic require-
ment before a license or reinstatement is granted.
Licenses granted to patients who have had sei-
zures should be renewed on an annual basis, con-
tingent upon the progress of the condition, the
absence of organic or psychiatric contraindica-
tions, and adherence to a well regulated regime
with relation to drugs and physical habits, in-
cluding strict abstinence from alcohol. Follow-
up information in addition to the physician’s
statement should include a social history from
relatives and others who are closely acquainted
with the case. The patient must be given to im-
derstand that his license to drive is directly de-
pendent upon a successful therapeutic plan, and
is by no means to be construed as official recog-
nition that he is “cured” or that preventive pro-
cedures may be relaxed.

Summary

Viewed solely from the standpoint of available
morbidity and mortality statistics, epilepsy and
epileptic disorders probably do not account for
a numerically alarming number of traffic acci-
dents. As a road hazard the danger of epilepsy
lies not in the frequency of its occurrence, but
rather, like lightning, in its suddenness and un-
predictability.

There is a real need for uniform regulations
in all states with regard to the operation of motor
vehicles by individuals who are subject to sei-
zures, and these should be according to a plan
which will not only insure maximum safety for

710

the patients as well as others, but also one which
would give physicians a means of adequately dis-
charging their obligation both to the patient and
to the community.

The danger of epilepsy in traffic situations can
be largely controlled by a comprehensive, socially
integrated, preventive approach. There is ever}^
likelihood that a concerted and efficient applica-
tion of all the medical and legal measures at
present at our disposal would bring the risk of
accidents due to epileptic disorders to a humanly
irreducible minimum.

References

Driver License Examination Procedure; American As=o-
mation of Motor Vehicle Administrators, 13, 1940.

Harvey, R. W.: EpilepsyL-A Re-

portable Disease. California State Dept, of Public Health
Weekly Bulletin, 18:28, 109, (Aug. 5) 1939.

CJibbs, F. A.; Electroencephalography in Epilepsy. Jour,
of Ped., 15:6, 749-762, (Dec.) 1939

and Motoring. Epilepsia,

Raphael, T., Labine, A. C., Flinn, H. L., and Hoffman,
h d Hundred Traffic Offenders. Mental Hygiene,

13:4, 809-824, (October) 1929.

Selling, L. S.: Annual Report of the Psychopathic Clinic
of the Recorder’s Court of the City of Detroit, 114, 1937.

MSMS

Intravenous or Retrograde
Pyelography?

By R. J. Hubbell, M.D.
and

Ra C. Hildreth, M.D.
Kalamazoo, Mich.

R. J. Hubbell, M.D.

B.S., Northwestern University, 1918. M.D.,

Northwestern University Medical School, 1923.
Diplomate, American Board of Urology.' Mem-
ber, American Urological Association, Amer-
ican Neisserian Medical Society, Michigan
State Medical Society.

R. C. Hildreth, M.D.

M.D., University of Nebraska College of
Medicine, 1932. Diplomate, American Board
of Radiology. Member of the Staff of Borgess,
Bronson Methodist and Sturgis Memorial Hos-
pitals._ Member, Radiological Society of North
America, America College of Radiology, Ameri-
can Roentgen Ray Society, American Radium
Society, Michigan State Medical Society.

■ Intravenous pyelography has been in use
about 10 years and is gradually assuming its
proper place in the diagnosis of urological lesions.
Uroselectan was introduced in 1929 by Von
Lichtenberg and Swick and has proved, indeed,
a boon in the diagnosis of urological lesions.
The formula of the iodine compound has been
improved so much that now it is quite an in-
nocuous substance in the vein or in the ureter.

Jour. M.S.M.S.

PYELOGRAPHY— HUBBELL AND HILDRETH

It was thought at first that this new pro-
cedure would replace the use of the cystoscope
and retrograde pyelography but, in spite of the
tremendous advance made in the use of this
substance, much ill-advised surgery must have
been, and will be, performed, if reliance is
placed solely on intravenous pyelograms. It
should be considered an adjunct and not a
complete diagnostic measure in most cases.

We made a sur^^ey of eighty-nine hospital
(or bed) cases in which intravenous pyelography
was done, the study of which serves as a guide
to the evaluation of this modality. Table I reveals
that females outnumber males to an appreciable
extent, probably due to the fact that there are
more abdominal complaints in women and
therefore they have more of a need for differ-
ential diagnoses.

TABLE I

Number of Intravenous Pyelograms 89

Sex :

Males . . 39

Females 50

Age:

Oldest 82 yrs.

Youngest 14 mos.

Average ' 50 yrs.

The oldest patient was eighty-two years and the
youngest was fourteen months ; in the latter case
the dye was given in the external jugular vein.
A simpler manner of administration when it is
difficult to get into the vein, or in the case of
infants, is that of Nesbit’s in which 20 c.c. of
the iodine compound is mixed with 80 c.c. of
normal saline and equal parts are injected over
each scapula subcutaneously, preceded, possibly,
by an injection of novocaine.^

Attention to certain details of technique will enhance
the value of intravenous pyelography. We believe it is
valuable to withhold fluids for at least twelve hours
before the pyelograms are made so as to give a better
concentration of the dye. One to two ounces of castor
oil are given the night before and, if not contraindi-
cated, ^ to 1 c.c. of pitressin is given one-half hour
before the intravenous dye is given.

Immediately before the dye is given the patient is
questioned as to his tendency to allergy or sensitiveness
to iodine compounds. If this condition is present, the
determination of the sensitivity to the dye should be
obtained b}^ the method of Dolan.^ He recommends
that 1 c.c. to 2 c.c. of the iodine substance be held in

the mouth for about ten minutes. If no reaction occurs,
the substance may be swallowed and one must wait
another thirty minutes to determine the possibility of
any sensitivity to the agent.

A slight Trendelenburg position is maintained
throughout the taking of the pictures unless an upright
position is desired for one of the films. In a group
of hospital patients where such a high percentage have
abdominal pain or renal colic and hence, usually,
considerable gas, and where urgency may prevent
adequate preparation of the patient, intravenous pyelog-
raphy is encumbered with radiologic technical diffi-
culties not usually found in the ambulatory patient.

Table II indicates the chief complaints of patients
on whom the intravenous pyelograms were done.

TABLE II

Chief Complaint Number

Pain 52

Frequency 7

Fever 6

Dysuria 3

Nausea and vomiting 0

Hematuria 2

Colic 0

Pyuria 1

Distention 1

Impotence 1

Diarrhea 1

Loss of weight and appetite 2

Anuria 1

Pruritis vulvae 1

Dyspnae 1

High blood pressure 1

Urgency 1

Nervousness 1

Not listed 7

Total number of cases 89

Pain in some part of the abdomen is by far the
most frequent symptom and this justly so. Where
symptomatology is indicative more of infection,
hematuria, or a purely urinary complaint, cystos-
copy and retrograde pyelograms will furnish the
most complete evidence and at less delay to the
patient.

Table III gives the diagnoses that were mad^
from intravenous pyelograms.

In sixteen cases or 18 per cent no diagnosis
could be made. Thirteen doubtful normal and
twenty-five definitely normal pyelograms make
thirty-eight cases or 42 per cent of the total.
Doubtful normals are those wherein a little
imagination is necessary to construct a picture of
a normal pelvis but because of the good excretion
of the dye and the remainder of the clinical

September, 1941

711

PYELOGRAPHY— HUBBELL AND HILDRETH

TABLE III

Diagnosis by Intravenous Pyelogram

No diagnosis

Doubtful normal

Normal

Dilation of :

Calices

Pelvis

Ureter

Bladder

Stone in :

Parenchyma

Calices

Pelvis

Ureter

Bladder

Ptosis

Kink of ureter

Anomaly

Tumor

Miscellaneous

Nephrogram

Stricture

Double kidney

Rotation

Anomalous vessel (?)

Bladder tumor

history, they can be classified as normal. Thirty-
four cases or 38 per cent give pictures of dila-
tion somewhere in the urinary tract. It is in this
instance that the intravenous pyelogram seems
to give the best definition. The remainder of the
cases are well distributed as to their oc-
currence.

Table IV reveals that a retrograde pyelogram
was indicated and done in twenty- four of the
cases. Indications for making the retrograde
pyelograms were simply that the intravenous
pyelogram could not tell us definitely and com-
pletely what pathology was present.

TABLE IV

Number of retrograde pyelograms 24

Diagnoses cotifirmed 10

Changes or additions in diagnoses
following retrograde pyelogram 14

In ten cases the diagnosis by intravenous
pyelography was confirmed and in fourteen cases
there was an additional diagnosis made, or the
diagnosis was changed by retrograde pyelogram.
If these latter fourteen cases are added to the
sixteen cases in which no diagnosis could be
made, there is a total of thirty cases (30 per cent

of the total) wherein intravenous pyelogram could |
not be relied upon as a diagnostic picture of the I
case. I

There were nine kidney operations done in \
which the diagnosis was confirmed in seven and |
changed in two instances. j

)

Conclusion

In conclusion it might be stated from these j
findings and experience that:

I. Patients of any age may be examined by
intravenous pyelography.

II. The intravenous method is indicated in :

1. Differential diagnosis of obscure abdominal
pain.

2. When the instrumentation of cystoscopy is

contraindicated or where one wishes to shorten |
the procedure as much as possible by first obtain- |
ing as much information as one can by intra- *
venous pyelography. .

3. Tuberculosis of the genito-urinary tract, as \

instrumentation in these cases should be kept at a '
minimum. |

4. Cases of stone, particularly in the kidney or '
ureter. Here intravenous pyelography is especial- f
ly helpful because of obstruction in the tract if !
the obstruction has not been present long enough
to embarrass the function of the kidney.

5. Double kidney or ureter which is sometimes ,
missed by retrograde method.

6. Trauma of the genito-urinary tract where
instrumentation is to be kept at a minimum.

7. Possible obstruction of the ureteral orifice by |

bladder tumor. I

III. The intravenous method is contraindicated I

in : i

1. Cases of known poor urinary function where i
pyelograms will not be obtained because no dye ’
is excreted by the kidney.

2. Idiosyncrasy to the dye or history of allergy,
particularly to iodine compounds, in which cases •
the determination of sensitivity should be obtained
by the method of Dolan.

IV. In about one-third of the cases a complete
diagnosis cannot be made by intravenous pyelog-
raphy.

References

1. Dolan, Leo P. : Allergic death due to intravenous use of
diodrast. Jour. A.M.A., 114:138-139, (Jan. 13) 1940.

2. Nesbit, R. M., and Douglas, D. B. ; Subcutaneous adminis-
tration of diodrast for pyelograms in infants. Jour. Urol.,
42:709, (Nov.) 1939.

Number

...16

...13

...25

...11
...18
... 5
... 0

... 3
. .. 3
.. . 2
... 8
... 0
. . . 4
... 6
... 0
. . . 1
... 1
. . . 2
... 0
.. . 1
.. . 1
... 2
... 1

712

Jour. M.S.M.S.

The Annual Meeting, and Farewell

The complete program of the 1941 Annual Meeting
of the Michigan State Medical Society appears in
this number. For a state medical society, it is imique
in quality, variety and size. Verily, it merits the
paraphrased title of "Michigan’s Medical World Fair.”

Doctor, peruse the program in this issue. Incidental-
ly the M.S.M.S. Journal, each and every month,
contains much information of value to you in your
practice. I recommend to each member the good habit
of carefully reading the monthly State Medical Jour-
nal. It will share important dividends with the
reader.

The final paragraph of this, my final page, is one
of sincere appreciation and thanks to all who helped
contribute to the progress of the year 1940-41. Any
success of this administration can be traced to the
generous work of our society committeemen and of-
ficers.

For my able successor, Henry R. Carstens, I solicit
the same loyal support that has been my fortunate lot.

President, Michigan State Medical Society

Pc

a^e

September, 1941

713

EDITORIAL X-

raS FATHER'S FOOTSTEPS

■ When Henry Carstens assumes the position

of president of the Michigan State Medical
Society at our Seventy-Sixth Annual Meeting in
Grand Rapids in September unusual history will
have been made, for it is the first time in the
many years of organized medicine in Michigan
and probably a most unusual coincidence in any
state that a son of a previous president of a state
medical society would achieve the same office.

Doctor Carstens’ father, J. Henr}^ Carstens,
was born in Kiel, Germany, on Jime 8, 1848 and
died in Detroit, August 7, 1920. The personal
and professional history of the first Doctor Car-
stens is most interesting and thrilling. He came
to Detroit with his parents as a small boy and
graduated from Detroit Medical College in 1870.
He began the practice of medicine immediately.
For nearly fifty years he had lectured and taught
various branches of medicine and surgery to gen-
erations of medical students. At the time of his
death he was the President of the Detroit College
of Medicine and Surgery and Professor of
Gynecology at the same institution. He was on
the staff at Harper Hospital and the Woman’s
Hospital. He had been president of the Wayne
County Medical Society, an office which has
already been filled by his illustrious son, and was
president of the Michigan State Medical Society
in 1909. He was a member of the Mississippi
Valley Medical Association, the American Gyne-
cological Association and the American College of
Surgeons. Doctor Carstens took a great deal of
interest in city politics and was candidate for
mayor of Detroit on several occasions. He was
formerly a member of the Detroit Board of Edu-
cation and the Detroit Board of Health. For
many years Doctor Carstens was an active mem-
ber of the Harmony Club and also belonged to
the Detroit Athletic Club and the Detroit Club.
Doctor Carstens was one of the most widely
known physicians not only in Michigan but
throughout the United States.

The story of the present Dr. Henry Carstens
hardly needs to be elaborated. After serving
for a number of years as a member of The Coun-

cil and as chairman of The Council he became
president-elect last year. It is of particular note
that he is governor of the American College of
Physicians for the State of Michigan. He has
been on The Council of the Wayne County Medi-
cal Society and has been its chairman. He is
the president and medical director of the Michi-
gan Medical Service and possesses an enviable
reputation as an internist.

His keen mental perception, his sense of fair-
ness and his unusual clear thinking mark him as
a man who will lead the Michigan State Medical
Society on to higher levels than ever before.

MSMS

YOUR WISH HAS COME TRUE

■ How many times have you wished, after
listening to a noted authority speaking at a
scientific meeting, that you could ask questions
or have some points made more clear to you?
Your wish has come true.

After the Wednesday and Thursday sessions
of the Annual Meeting of the Michigan State
Medical Society, a discussion period will be
held for the various departments of medicine
at which the invited essayists will answer in-
quiries. It is something new, an innovation
which makes one of the greatest of the state
medical meetings even more valuable to you
than before.

Sixteen of the world’s best qualified
specialists will present their views and
findings to you in a public address, on
these days, and then be available for your
further questions at the close of the after-
noon session. All the meetings are held
in the same Civic Auditorium in the
“Furniture Capital of America,” the second
city of Michigan.

If you are interested in medical progress
you must attend the Seventy-Sixth Annual
Meeting of the Michigan State Medical Society,
September 17, 18, and 19; the biggest three
days in medicine that Michigan has ever
known.

714

Jour. M.S.M.S.

WHAT ABOUT GRAND RAPIDS?

Grand Rapids, the mecca for Michigan Medi-
cine September 17, 18 and 19, has an interesting
history with its rapid and distinctive industrial
development. It is the second city in size in this
state. The annual conventions of the Michigan
State Medical Society have become so large that
only two cities in the state have convention halls
sufficient to accommodate the meetings, as well as
exhibits which have become a most important fea-
ture of the annual meetings within recent years.
The evolution of scientific medicine has caused
a great development by way of invention of diag-
nostic and treatment equipment as well as refine-
ment in drugs and foods intended for the sick.

Grand Rapids, we repeat, has an interesting
history. The name is descriptive of the rapids in
the Grand River. A little over a hundred years

Butterworth Hospital

ago, one hundred and fifteen to be exact, Louis
Campau, a French pioneer, established a trading
post there, purchasing the ground for ninety dol-
lars. A second pioneer was Lucius Lyon, who,
having surveyed the site for the government, had
intended to buy it for himself. He was forced to
purchase it, however, from Campau at a much
higher price. It is said that this transaction re-
sulted in an estrangement between the two pio-
neers, the effect of which is seen in the present pe-
culiar layout of the downtown district of the city.
The two pioneers disagreed as to the name of the
locality. Campau insisted on the name “Grand
Rapids,” while Lyon wanted it called “Kent” af-
ter a chancellor of New York state. The name of
Chancellor Kent, however, is perpetuated in the
name of the county. All this is a matter of his-
tory.

Located in the midst of a lumbering district,
from the beginning prosperity was assured to the
town. Perhaps for more than anything else.
Grand Rapids today is preeminently known
throughout the nation as the Furniture City of
America, just as Detroit is known throughout the
world as the great automobile center.

Grand Rapids is characterized by the diversity
of its industrial operations, best known of which
is furniture manufacturing for which it is known
the world over. There are more than 500 manu-
facturing establishments in the city, producing

September, 1941

715

GRAND RAPIDS— CONVENTION CITY

more than 2,500 different products which are
grouped mainly into woodworking, metalworking
and miscellaneous. In the latter group are sev-
eral large subdivisions including graphic arts, food

St. Mary’s Hospital

products, paper products, gypsum mining and
products, chemicals and textiles.

The metal industry vies for importance with
the woodworking industry. A large number of
plants are devoted to producing a wide variety of
metal products including woodworking and met-
alworking machinery; hardware for automobiles,
furniture, refrigerators, plumbing and building;
automobile bodies and trailers and parts. This
industry which employs thousands of men is one
I of the most rapidly developing industrial groups
and is a very important factor in the economic
"well-being of the community.

Also Grand Rapids contains the largest sticky
fly paper factory in the world, the largest pro-
ducers of school, church and theater seats, car-
pet sweepers, metal belt lacers, gypsum products,
window sash pulleys, paper boxes, automatic
musical instruments and plumbing and bathroom
fixtures. In order to indicate the versatility of
Grand Rapids’ manufacturing, a short list of a
variety of products made there might prove in-
teresting. Bodies for several nationally known
makes of automobiles are built here. Its other
contributions to the automotive world include na-
tionally known tires and bumpers, as well as
metal dash boards, hardware, refinements for
car interiors, seat and back springs, and other
parts and minor accessories.

To this list of Grand Rapids-made products
may be added leather belting, cigars, mattresses.

springs, bedding, flour, paints, varnishes, extracts,
perfumes, filing devices, metal furniture and cab-
inets, underwear, hosiery, clothing, infants’ and
children’s dresses, toilet preparations, factory
trucks, factory conveyors, wrought iron products,
elevators, emblem jewelry, radiator covers, motor
boat propellers, face cream, fibre cord, laminated
wood products, soaps and washing powders, la-
dies’ ready-to-wear, crackers, candies, band in-
struments, golf clubs, golf balls, ski equipment
and sporting goods. With attractive advantages
to offer, negotiations are constantly being carried
on to further extend the manufactories in this
community.

Grand Rapids stands high as a printing cen-
ter. There are some 60 plants in the city, and
among them are producers of photoengraving,
lithography, printing and very high-grade adver-
tising literature.

The inhabitants of the city number 176,000.
There are 2,560 retail establishments, 80 schools,
150 churches, 11 hotels and 27 theaters. Grand

Blodgett Hospital

Rapids is a city with a personality. It is essen-
tially a city of homes, ministered to spiritually
and culturally by the number of churches and
schools mentioned. The material wants of the
inhabitants are supplied by four large depart-
mental stores and scores of small smart shops.
It seems scarcely necessary to comment on Grand
Rapids as a convention city, since the fact is
already known to the medical profession of the
state which has met there a number of times
and has partaken of the hospitality of the city.
The medical profession of Grand Rapids is pro-
gressive and equal in ability to that of any city
on the continent.

716

Jour. M.S.M.S.

THE 7BTH AMNUAl MEETING

GRAND RAPIDS - 1941

CONVENTION INFORMATION

DIRECTORY

Headquarters and Registration. .. .Civic Auditorium
Telephone: 9-1454 and 9-1475

Hotel Headquarters .Pantlind Hotel

Scientific and Technical Exhibits . . Civic Auditorium
General Assemblies, Black and Silver Ballroom

Civic Auditorium

Publicity, Press Room . . Room A, Civic Auditoriiun
Telephone: 9-7201

M.S.M.S. Hospitality Booth

Exhibit Floor, Civic Auditorium
Woman’s Auxiliary, Headquarters and Registra-
tion Pantlind Hotel

* * *

Register — Exhibit Floor, Civic Auditorium, Grand
Rapids — as soon as you arrive.

Hours of Registration daily 8:30 a.m. to 6:00 p.m.
on Tuesday, Wednesday and Thursday, September 16,
17, 18, and to 3:30 p.m. on Friday, September 19.

Admission by badge only, to all scientific assemblies
and section meetings. Monitors at entrance.

Bring your M.S.M.S. or A.M.A. Membership Card
to expedite registration.

No registration fee to members of the Michigan State
Medical Society.

* ♦ ♦

Guests — Members of the American Afedical As-
sociation from any state, or from a province of Canada,
and physicians of the Army, Navy and U. S. Public
Health Service are invited to attend, as guests. Please
present credentials at Registration Desk.

Bona fide doctors of medicine serving as interns,
residents, or who are associate or probationary mem-
bers of county medical societies, if vouched for by an
M.S.M.S. Councilor or the president or secretary of the
county medical society, will be registered as guests.
Please present credentials at Registration Desk.

* !l! SK

Physicians, not members, if listed in the American
Medical Directory, may register as guests upon pay-
ment of $5.00. This amount will be credited to them
as dues in the Michigan State Medical Society FOR
THE BALANCE OF 1941 ONLY, provided they sub-
sequently are accepted as members by their County
Aledical Society.

* * *

The Michigan State Medical Society Hospitality
Booth is adjacent to the Registration Desk at the
entrance of the Exhibit Hall. An M.S.M.S. Councilor
or Officer will be in attendance at all times. Members
are invited to stop at the Headquarters and meet the
President and other M.S.M.S. officers.

♦ * *

Register at Each Booth — There is something new
for you in the interesting and large exhibit (110 booths).
Stop and show your appreciation of the exhibitors’ sup-
port in making the Convention possible.

September, 1941

Telephone Service — Local and Long Distance tel-
ephone will be available at entrance to Black and Sil-
ver Ballroom in the Civic Auditorium, as well as in the
Pantlind Hotel.

In case of Emergency, doctors will be paged from the
meetings by announcement on the screen. Telephone
numbers in the lobby of the Black and Silver Ballroom
are: 9-1547; 9-1716; 9-1738. The Pantlind Hotel tele-
phone number is : 9-7201.

* * *

Seven General Assemblies, Wednesday, Thursday
and Friday, September 17, 18, 19.

♦ * *

The Seven Section Meetings will be held on Fri-
day morning only, September 19. Ltmcheons will be
sponsored by the Sections on

1. Obstetrics and Gynecology.

2. Ophthalmology and Otolaryngology.

3. Dermatology and Syphilology.

DISCUSSION CONFERENCES

These quiz periods will be held Wednesday and
Thursday, September 17 and 18, 3 :30 to 4 :30 p.m.
An opportunity to ask questions or to discuss one
' of your interesting cases with the guest-essayist
will be provided.

Please submit your questions, on forms printed
in the program, to the Secretary of the General
Assembly immediately after the termination of
the lecture, in order that the guest essayist may
have time to consider same before the quiz pe-
riod.

Public Meeting — The evening assembly of

Wednesday, September 17 — President’s Night — will be
open to the public. Invite your patients and other
friends to this interesting meeting. The program
(complete on page 726) is highlighted by:

8:00 p.m. President’s Address

Induction of President-Elect.

9:00 p.m. Biddle Oration.

10 :00 p.m. Entertainment (floor show) and dancing.

=K * *

Checkrooms are available in the Pantlind Hotel,
and in the lobby of the Exhibit Hall, Civic Auditorium.

■ MICfflGAN MEDICAL SERVICE

Second Annual Meeting of the Michigan Medi-
cal Service Membership will be held Wednesday,
September 17, 4 :30 p.m. in the Swiss Room, Pant-
lind Hotel. Members of Michigan Medical Serv-
ice are all the members of the M.S.M.S. House
of Delegates plus the Director of Michigan Medi-
cal Service. The Officers’ Reports and Election
of Directors will be on the agenda of the Annual
Meeting.

717

THE SEVENTY-SIXTH ANNUAL MEETING

PAPERS WILL BEGIN AND END ON
TIME!

Believing there is nothing which makes a scien-
tific meeting more attractive than by-the-clock
promptness and regularity, all meetings will op-
en exactly on time, all speakers will be required
to begin their papers exactly on time, and to
close exactly on time, in accordance with the
schedule in the program. All who attend the
meeting, therefore, are requested to assist in
attaining this end by noting the schedule care-
fully and being in attendance accordingly. Any
member who arrives five minutes late to hear
any particular paper will miss exactly five min-
utes of that paper !

The Committee Organization Luncheon, a meet-
ing of M.S.M.S. committee chairmen appointed by
President-Elect Carstens to serve during the year 1941-
42, will be held on Wednesday, September 17, 1941,
12:30 p.m. in the Furniture Assembly Room, Pantlind
Hotel.

* sK sK

American Medical Women’s Association, Michi-
gan Branch, will meet Tuesday, September 16, Pantlind
Hotel, 1:00 p.m. (luncheon), followed by a business
meeting at 2 :00 p.m.

At the 6 :30 p.m. dinner, Myra Babcock, M.D., Detroit,
will speak on “Status of Women Physicians in the
National Defense Program,” followed by a round-table
discussion.

All women physicians are cordially invited to attend
this meeting.

A Special Meeting of M.S.M.S. Delegates
will be held Monday, September IS, 1941 at 8:00
p.m. in the Swiss Room, Pantlind Hotel, Grand
Rapids. All M.S.M.S. Delegates and members
are invited and urged to attend this session at
which the Afflicted-Crippled Child Laws, Medical
Welfare, Michigan Medical Service, and other
subjects will be discussed.

The Michigan Branch of the American Academy
of Pediatrics will hold a dinner in the Pantlind Ho-
tel, Thursday evening, September 18, 6:30 p.m. W. C.
C. Cole, M.D., 1077 Fisher Building, Detroit, is in
charge of arrangements.

* * *

The Northwestern University Medical School
Alumni luncheon will be held at the Peninsular Club,
Grand Rapids, Thursday, September 18, at 12:15 p.m.

All Northwestern Medical School Alumni are cor-
dially invited to attend this luncheon. E. W. Schnoor,
M.D., 216 Medical Arts Bldg., Grand Rapids, President
of the Northwestern A-1 Club of the host city, is Chair-
man.

* *

Acknowledgment — The Michigan State Medical
Society sincerely thanks the following friends for their
sponsorship of lectures at the 1941 meeting:

Sponsor Lecturer

Children’s Fund of Michigan

Borden S. Veeder, M.D., St. Louis, Mo.

W. K. Kellogg Foundation

James R. McCord, M.D., Atlanta, Ga.

Michigan Department of Health

Anthony J. Lanza, M.D., New York City.

Michigan Tuberculosis Association

Charles E. Lyght, M.D., Northfield, Minn.

Essayists are very respectfully requested not to
change time of lecture with another speaker without
the approval of the General Assembly. This request
is made in order to avoid confusion and disappointment
on the part of the audience.

SMOKER

Thursday, September 18, at 9 :00 p.m.. Ballroom,
Pantlind Hotel. Admission by card to members
only.

Scientific and Technical Exhibits — 110 displays —
will open daily at 8:30 a.m. and close at 6:00 p.m. with
the exception of Friday, when the Exhibits will close at
3 :00 p.m. Intermissions to view the exhibits have been
arranged during the morning and afternoon General
Assemblies.

Please Register at Each Booth
* * *

Golf Tournament — ^Monday, September 15, 1941,
beginning at 12:00 Noon at beautiful Kent Coimtry
Club. Plan to participate in this 18-hole tournament
and win a prize. Competition open to all members of
the Michigan State Medical Society. Five Flights, for
Beginners, Dubs and Experts. Banquet and presenta-
tion of prizes at Kent C. C., 6^:30 p.m. The price : $3.00.

^ ^

Parking — Do not park your car on the street.
Convention parking near the Civic Auditorium will be
marked off with suitable sidewalk signs. The Grand
Rapids Police Department will issue courtesy cards (at
Registration Desk) for out-of-town autos, which give
parking privileges but do not apply to metered spaces.
Nearby parking lots are available, as well as convenient
indoor parking facilities. The indoor parking rates at
the Pantlind Garage is 50 cents for twenty-four hours.
Parking is free for twenty-four hours with one of
the following services: (a) car wash; (b) complete
lubrication; (c) oil change; (d) purchase of 10 gallons
of gasoline.

COUNTY SECRETARIES’ CONFERENCE
Grill Room Pantlind Hotel

Wednesday, September 17, 1941
LUNCHEON — 12:00 to 1:30 p.m.

E. B. Andersen, M.D., Iron Mountain, Presiding.

John M. Pratt

All Members of the
Most Welcome c

Program

“What’s Going on in
Michigan” (10 min.)

L. Fernald Foster, M.D.,
Bay City,

Secretarj^, Michigan State
Medical Society.

“What’s Going on in
Washington” (30 min.)
John M. Pratt, Chicago,
Executive Administrator,
National Physicians
Committee.

State Society will be
t This Conference

718

Jour. M.S.M.S

THE SEVENTY-SIXTH ANNUAL MEETING

Symposium on

“THE BUSINESS SIDE OF MEDICINE”
Grill Room

Pantlind Hotel — Grand Rapids
Tuesday, September 16, 1941

I

12:30 to 4:30 p.m.

(Subscription Luncheon, 12:20 p.m.)

Program •

Wilfrid Haughey, M.D., Battle Creek, Presiding

1. Welcome

Henry R. Carstens, M.D., Detroit, Presi-
dent-Elect, Michigan State Medical So-
ciety

2. Michigan Medical Service Billing

L. Fernald Foster, M.D., Bay City, Mem-
ber, Board of Directors, MMS.

3. “Better Records in Half the Time”

John J. Wells, Detroit, Manager, The
Physicians Bookkeeper

4. “Handling the Doctor’s Accounts Receivable
Problem”

Stanley R. Mauck, Columbus, Ohio, Presi-
dent, National Association Professional
Bureau Managers

5. Round-table discussion

Led by R. G. Leland, M.D., Chicago,
Director, Bureau of Medical Economics,
American Medical Association

Preview of M.S.M.S. Technical Exhibit
(4:30 to 5:15 p.m.)

This meeting is arranged especially for the secretaries
and office assistants of members of the Michigan State
Medical Society. Physicians are urged to send their
office secretaries to this meeting; the stiggestions and
ideas offered at this session will more than replay the
doctor for doing so. There is no registration fee, only
a charge made by the hotel for luncheon.

Guest Golf — The Chairman of the Grand Rapids
Committee has arranged that IM.S.M.S. members may
play at all country clubs in the Grand Rapids District
upon presentation of M.S.M.S. Membership Card and
payment of greens fees.

Wm. A. Hyland, M.D., Metz Building, Grand Rap-
ids, is General Chairman of the G. R. Committee on
Arrangements for the 1941 M.S.M.S. Convention.

He *

Postgraduate Credits given to every member who
attends the M.S.M.S. General Assembly, Wednesday,
Thursday, Friday, September 17, 18, 19, at Grand Rapids

He He He

Press Committee: J. Duane Miller, M.D., Chair-
man; Leon DeVel, M.D., and Torrance Reed, M.D.

He

H? 3|c

R. A. Bier, M.D.

“The Physician in Nation-
al Defense” will be the sub-
ject of a brief presentation by
Robert A. Bier, M.D., Major,
Medical Corps, Medical Head-
quarters for the Selective Serv-
ice System, Washington, D. C.
This ten-minute talk will be
given at the Third General As-
sembly — President’s Night —
Wednesday, September 17, 8:30
p.m. in the Ballroom of the
Pantlind Hotel.

Andrew P. Biddle, M.D.,

well-known patron of Post-
graduate Medical Education in
Michigan, will present the Bid-
dle Oration Scroll to Alphonse
Schwitalla, S.J., Dean, St.
Louis Medical School, Septem-
ber 17, 9 :00 p.m.. Ballroom,
Pantlind Hotel.

A. P. Biddle, M.D.

To the MSMS Convention!

September, 1941

719

SCENTinC EXHIBITS

I University of Michigan Medical School
“V entricnlog^aphy”

This diagnostic procedure requires numerous
technically perfect roentgenograms of the skull
made in several projections. For this exhibit only
the most diagnostic films of each case have been
selected and they display deformities of the ven-
tricular system caused by tumors involving all
parts of the brain.

II Wayne University College of Medicine,

Department of Medicine
in collaboration with the
Michigan State Department of Health
“Treatment of Pneumococcic Pneumonia”

This exhibit covers diagnosis, prognosis, general
management and specific treatment of jineumo-
coccic pneumonia. Detailed consideration is given
to sulfathiazole and serum. Results with sulfa-
thiazole are presented and toxic manifestations
are illustrated. Representative cases are included,
to show the clinical response to specific treatment
and the effect of serum and chemotherapy upon
pneumococci in the sputum.

III W. K. Kellogg Foundation,

Battle Creek

The W. K. Kellogg Foundation scientific exhibit
will be a series of colored photographs showing
the methods through which the Foundation is as-
sisting in the improvement of medical practice.
At present the efforts of the Foundation are con-
fined to the seven counties of Allegan, Barry,
Branch, Calhoun, Eaton, Hillsdale, Van Buren.
The Foundation is assisting the doctors in three
ways: 1. Providing opportunities and fellowships
for education. 2. Assisting in the provision of
medical facilities — (a) Hospital, (b) X-ray,

(c) Clinical Laboratory, (d) Nursing, (e) Consul
tative, 3. Preventive Medicine. The Foundation
provides financial assistance for promoting medi-
cal examinations, immunizations, tuberculosis ex-
aminations. It also assists in subsidizing health
departments which co-operate with the medical
society in the development of preventive pro-
grams. There are no clinics in this area and the
policies and procedures are developed by the
county medical society itself.

IV Michigan Department of Health
Lansing, Michigan

“Care of Premature Infants”

The Michigan Department of Health will display
equipment for the care of premature infants. The
Department’s recently developed incubator will be
demonstrated together with types of heated beds.
Charts will show premature death rates by coun-
ties and maps will indicate locations of hospitals
to which incubators have been loaned by the
Department.

V Blodgett Hospital

Grand Rapids, Michigan

1. The treatment of burns from the corrective
and Plastic Surgery standpoint. This is an ex-
hibit demonstrating the skin grafting of re-
cent burns, and the management of scars, con-
tractures, and deformities resulting from
burns.

2. A teaching exhibit for the General Practition-
er, showing typical x-ray findings in the more
common bone tumors, both benign and malig-
nant— a minimum of reading material.

3. Diabetes Mellitus. An exhibit showing the
causes of glycosuria with the differential diag-
nosis.

VI Butterworth Hospital

Grand Rapids, Michigan

“Clinical Analysis of 550 Endometrial Biopsies”

A clinical analysis of 550 endometrial biopsies is
presented by the Department of Gynecology and
the Department of Pathology of Butterworth Hos-
pital. While this material represents a study of a
variety of gynecological conditions, our interest
is chiefiy concerned with the clinical analysis of
the factors involved in 55 consecutive sterility
patients. Endometrial biopsies showed that the
dominant sterility factor in 12 patients of this

group was due to failure of ovulation. Eight of
these anovulatory patients were given injectiona
of mare’s serum. Subsequent endometrial biop-
sies showed evidence of ovulation in all but one
patient of the treated group. These results are
outlined in case history form and illustrated by
photomicrographs.

VII St. Mary’s Hospital

Grand Rapids, Michigan

“St. Mary’s Hospital — a Tribute to the Sisters of ■
Mercy — Pioneer Nurses of Michigan”

This exhibit will depict a scene in the first Mercy
Hospital of Michigan during the early lumbering
days. Equipment, costumes and instruments will
be on display as used during that period in the
care of the sick and injured.

VTII Medical Superintendents of
State Hospitals

Demonstration of Neuropathologie Specimens by
the Michigan State Hospitals for Mental Disease
and the Neuropsychiatric Institute

Neuropathologie exhibit of about 150 specimens
which represent: 1. Gross specimens of the brain
showing various organic diseases of particular
interest to the physician in general practice.
2. Diagrams illustrating heredity in nervous and
mental disorders. 3. Photographs of specimens
showing particularly marked pathologic changes.

4. Large brain sections for uemonstrations of tu-
mors, gross cerebral atrophy and other conditions
of interest.

IX Michigan Tuberculosis Association
Lansing, Michigan

“Chest X-ray Methods”

Exhibit showing comparison of various methods
of making chest roentgenograms, in private prac-
tice and mass surveys, with brief comments on
advantages and disadvantages of each method.
The methods included are: Fluoroscope, single

14 X 17 film, stereoscopic films, paper roll, fluorog-
raphy with 35 mm. film and fiuorography with
4x5 film. Each method is shown by (a) diagram
illustrating the basic physical principles; (b) pho-
tograph of the apparatus; (c) actual x-ray;
(d) brief comments. The X-ray films and photo-
graphs are all of the same case. Across the top of
the exhibit are transparencies done in the Iso-
type technic of the various methods illustrated.

X U. S. Army

Selective Serviee System

“Military Information”

To aid the members of the medical profession
who may attend the State Convention, arrange-
ments have been made to have qualified represen-
tatives of the Army Medical Corps and a repre-
sentative of State Selective Service Headquarters
available at the Military Information Booth in
the Exhibit Hall during the Convention. Informa-
tion on commissions in the Medical Department
of the Army, Navy and Marine Corps may be
obtained from official representatives. Questions
concerning examination of selectees may be an-
swered by the official representative of Selective
Service.

XI American Medical Association
Chicago, Illinois

“Use and Abuse of Barbiturates”

An exhibit from the Council on Pharmacy and
Chemistry consisting of posters showing the use
and abuse of the barbiturates; a chart giving the
names and chemical formulas of thirty products
on the market; an exposition file and New and
Nonofficial Remedies giving additional informa-
tion.

XII American College of Surgeons
Grand Rapids Committee of
Regional Fracture Committee
“Fracture Exhibit”

Photographs of fracture films and exhibit of
splints, also fracture primers will be shown.

Jour. M.S.M.S.

720

THE SEVENTY-SIXTH ANNUAL MEETING

PROGRAM SYNOPSIS

MONDAY, SEPTEMBER 15

12:00 Noon M.S^M.S. Golf Tournament

Kent Country Club, Grand Rapids
3 : 00 P.M. Meeting of The Council, M.S.M.S.

Service Club Lounge, Pantlind Hotel
6:30 P.M. Golfers’ Banquet and Presentation of
Prizes

Kent Country Club

8:00 P.M. Special Meeting for Delegates and
Members

Swiss Room, Pantlind Hotel

TUESDAY, SEPTEMBER 16

8:00 A.M.
9:00 A.M.
12: 30 PAI.

3:00 P.M.
5:15 P.M.

8:00 P.M.

Delegates’ Breakfast
Swiss Room, Pantlind Hotel
First Session, House of Delegates
Grand Ballroom, Pantlind Hotel
Symposirun on “Business Side of Medi-
cine’’

Grill Room, Pantlind Hotel
Second Session, House of Delegates
Grand Ballroom, Pantlind Hotel
Preview of Scientific and Technical Ex-
hibits for members of House of Dele-
gates and M.S.M.S. Officers

Exhibit Floor, Civic Auditorium
Third Session, House of Delegates
Grand Ballroom, Pantlind Hotel

WEDNESDAY, SEPTEMBER 17

8:30 A.M.
9:30 A.M.

12:00 Noon
12:30 P.M.

1:30 P.M.

3:30 P.M.
4:30 P.M.

5:30 P.M.

8:30 P.M.

Registration : Exhibits Open

Exhibit Floor, Civic Auditorium
First General Assembly

Black and Silver Ballroom, Civic Au-
ditorium

(For detailed program see page 723)
Coimty Secretaries’ Conference
Grill Room, Pantlind Hotel
Committee Organization Luncheon
Furniture Assembly Room, Pantlind
Hotel

Second General Assembly

Black and Silver Ballroom, Civic Au-
ditorium

_(For detailed program see page 725)
Discussion Conferences
(See Outline, page 724)

Second Annual Meeting of Members of
Michigan Medical Service
Swiss Room, Pantlind Hotel
Meeting of Board of Directors, Michi-
gan Medical Service

Room 122, Pantlind Hotel
Third General Assembly — PRESI-
DENT’S NIGHT — ^PUBLIC MEETING
Ballroom, Pantlind Hotel
(For detailed program see page 726)

THURSDAY, SEPTEMBER 18

8:30 A.M.
9:30 A.M.

1:30 PAI.

3:30 P.M.

6:30 P.M.
9:00 P.M.

Registration: Exhibits Open

Exhibit Floor, Civic Auditorium
Fourth General Assembly

Black and Silver Ballroom, Civic Au-
ditorium

(For detailed program see page 756)

Fifth General Assembly

Black and Silver Ballroom, Civic Au-
ditorium

(For detailed program see page 728)
Discussion Conferences
(See (Dutline, page 724)

Fraternity and Alumni Banquets
Sixth General Assembly — SMOKER

(For Members Only)

Ballroom, Pantlind Hotel
(For detailed program see page 728)

September, 1941

8:30 A.M.
9:00 A.M.
8:30 A.M.

9:30 A.M.

9:30 A.M.
9:00 A.M.
9:00 A.M.
9:30 A.M.

9:30 A.M.

1:30 P.M.

4:30 P.M.

FRIDAY, SEPTE3IBER 19

Registration : Exhibits Open

Exhibit Floor, Civic Auditorium
Meetings of Sections

(1) Section on General Medicine
Ballroom, Pantlind Hotel
(See page 729)

(2) Section on Surgery

Black and Silver Ballroom, Civic Au-
ditorium
(See page 729)

(3) Section on Obstetrics and Gynecol-
ogy

Grill Room, Pantlind Hotel
(See page 730)

(4) Section on Ophthalmology and Oto-
laryngology

Ophthalmology

Room F, Civic Auditorium
(See page 730)

Otolaryngology

Room G, Civic Auditorium
(See page 730)

(5) Section on Pediatrics
Swiss Room, Pantlind Hotel
(See page 731)

(6) Section on Dermatology and Syphll-
ology

Directors Room, Civic Auditorium
(See page 731)

(7) Section on Radiology, Pathology
and Anesthesia

Red Room, Civic Auditorium
(See page 732)

Seventh General Assembly

Black and Silver Ballroom, Civic Au-
ditorium

(For detailed program see page 733)
End of 1941 Convention

Councilor Districts
of the

Michigan State Medical Society

721

THE SEVENTY-SIXTH ANNUAL MEETING

WOMAN'S AUXILIARY

Mrs. R. V. WalkEr
President

GRAiVD RAPIDS CONVENTION COMMITTEE

Mrs. Thomas C. Irwin, Chairman
Mrs. A. V. Wenger, Co-Chairman
Mrs. Henry J. Vandenberg, Banquet
Mrs. Henry J. Pyle, Finance
Mrs. George H. Southwic'k, Flowers
Mrs. Merrill M. Wells, Hospitality
Mrs. Leon C. Bosch, Printing
Mrs. William A. Hyland, Liuncheon
Mrs. R. S. VanBree, Publicity
Mrs. W. D. Lyman, Registration
Mrs. Carl F. Snapp, Transportation

Mrs. T. C. Irwin
Convention Chairman

OFFICERS, 1940-41

Mrs. Roger V. Walker, Detroit President

Mrs. William J. Butler, Grand Rapids

President-elect

Mrs. Oscar D. Stryker, Fremont Vice President

Mrs. A. O. Brown, Detroit Secretary

Mrs. H. L. French, Lansing Treasurer

Mrs. L. G. Christian, Lansing Past President

Mrs. Guy L. Kiefer, East Lansing

Honorary President

PROGRAM

Tuesday, September 16, 1941

10:00 A.M. Registration — Pantlind Hotel

1 : 00 P.M. Limcheon, Pre- convention Board Meet-
ing— Woman’s City Club, 1940-41
Board Members and County Presidents

Wednesday, September 17, 1941

10:00 A.M. Registration — Pantlind Hotel

10:30 A.M. Formal Opening of Convention — ^Kent
Country Club

Presiding — Mrs. Roger V. Walker, De-
troit

Address of Welcome — ^Mrs. Charles F.

Ingersol, Grand Rapids
Response — Mrs. Oscar D. Stryker, Fre-
mont

In Memoriam — Mrs. K. L. Crawford,
Kalamazoo

Reading of Minutes — Mrs. A. O. Brown,
Detroit

Report of Treasurer — Mrs. H. L.
French, Lansing

Auditor’s Report — Mrs. H. L. French
Report, Convention Chairman — Mrs.

Thomas C. Irwin, Grand Rapids
Credentials and' Registration — Mrs.

W. D. Lyman, Grand Rapids
Report of Special Committee and Pres-
ident’s Message — Mrs. Roger V.
Walker

Reports of Standing Committees
Report of Committee on Nominations
Election and Installation of Officers
Presentation of Pin
Courtesy Resolutions
Adjournment

1 : 00 P.M. Luncheon at Kent Comitry Club

Presiding — Mrs. Thomas C. Irwin
Presiding Officer — Mrs. Roger V. Walk-
er

Reports of County Presidents
Adjournment

4 : OO P.M. Post Convention Board Meeting

Presiding — Mrs. William J. Butler,
Grand Rapids

1941-42 — Board Members and County
Presidents

8:30P.M. President’s Night, Michigan State Med-
ical Society, Pantlind Ballroom. Floor
show and dancing.

For M.S.M.S. members, their wives and
guests

Thursday, September 18, 1941

6:30 P.M. Reception for National President, Past
Presidents of Michigan Auxiliary and
Board Members

7 : 00 P.M. Banquet — Swiss Room, Pantlind Hotel

Presiding — Mrs. Roger V. Walker, De-
troit

Chairman — Mrs. Thomas C. Irwin,
Grand Rapids

Introduction of Past Presidents
Address — Mrs. R. E. Mosiman, Seattle,
Washington, National President,
Woman’s Auxiliary to A.M.A.
One-act play

722

Jour. M.S.M.S.

PROGRAM of GENERAL ASSEMBLIES

WEDNESDAY MORNING
September 17, 1941

First General Assembly

Black and Silver Ballroom — Civic Auditoritmi

A. S. Brunk, M.D., Presiding

L. Ferxald Foster, and Roger V. Walker, M.D.,

Secretaries

A. M.

9:30 “Arthritis — A Curable Disease?”

Russell L. Cecil, M.D., Xew York City

B.A., Princeton University,
1902; M.D. Medical College
of Virginia, 1906; Sc.D.,
Medical College of Virginia,
1928. Entered Army in
June, 1917; served as Di-
rector of Laboratories at
Camp Upton, N. F., and
Camp Wheeler, Georgia;
served at Army Medical
School and appointed Head
of Coinmission for Study of
Pneumonia by Surgeon Gen-
eral, 1917 to 1919. He is
novc Professor of Clinical
Medicine, Cornell University
Medical School; Professor of
Medicine. Polyclinic Medical
Russell L. Cecil School and Hospital; he also
holds several other important
appointments. Doctor Cecil has published several
■works on the subjects of pneumonia, arthritis and
rheumatism.

The curability of arthritis varies with the type.
Some of the specific forms, such as gonococcal or
meningococcal arthritis, are readily curable by
sulphonamide therapy. The arthritis of rheumatic
fever usually yields promptls" to salicylates, but un-
fortunately the cardiac injury persists. Subacute
infectious arthritis often disappears permanently after
a focus of infection has been removed. Rheumatoid
arthritis is an extremelj- dif&cult disease to cure,
though a certain small percentage of these patients
do make a permanent and complete recovery. More
often the life history of the disease is characterized
by “ups and downs,” which go on indefinitely, with
periods of remission being followed by periods of
exacerbation. Gold salts offer more promise of
permanent relief in the treatment of rheumatoid
arthritis than any other remedy so far described.

Osteo-arthritis is also a chronic persistent ailment
which may yield readily to rest and physiotherapy,
but has a strong tendency to return when the joints
are overused. Gouty arthritis starts with acute at-
tacks from which the patient recovers completely
when treated promptly with colchicine. Chronic
gouty arthritis does not jdeld so quickly to remedial
agents.

MSMS

There are eleven golf courses on any of which
it will be possible to arrange for you to play while
attending the Annual Meeting of the Michigan
State Medical Society, September 17, 18, and 19 at
Grand Rapids.

M S M S

You will have an opportunity to visit the only
furniture museum in the United States (which in-
cludes exhibits of original masterpieces, modem
creations of master designers and craftsmen and ex-
hibits of the development of the furniture industry
of Grand Rapids and furniture manufacturing ma-
terial^ and processes) while attending the Annual
Meeting of the Michigan State Medical Society, Sep-
tember 17, 18, and 19 at Grand Rapids.

September, 1941

10:00 “Acute Appendicitis — A Twenty-five Year
Study”

Elliott C. Cutler, ^I.D., Boston
(Stanley O. Hoerr, ]M.D., Boston, Associate
in Study)

A.B., Harvard, 1909; M.D.,
Harvard Medical School,
1913; Honorary Doctorate,
University of Strasbourg,
1938. Served in World War
as Major, Medical Corps; Lt.
Colonel, Medical Corps Re-
serve, since 1924; decorated
■with Distinguished Serince
Medal. Chairman. Depart-
ment of Surgery, and Direc-
tor of Laboratory of Surgical
Research, Harvard, 1922-24;
Professor of Surgery, West-
ern Reserve University
School of Medicine, 1924-32;
Consulting Surgeon, Xe-a.'
England Peabody Home for
Elliott C. Cutler Crippled Children, 1932 to
present; Moseley Professor
of Surgery, Harvard, 1932 to present; Surgeon^in-
Chief, Peter Bent Brigham Hospital. Doctor Cutler is
a member of many medical and social organizations.

The deaths from acute appendicitis occur, as is
well known, in patients in whom peritonitis has
already developed when they first reach the hos-
pital. Early diagnosis and avoidance of catharsis
through education both of the laity and the profession
remains as important today as it was twenty-five
years ago. Today, however, strict attention to the
details of pre-operative and postoperative management,
including fluid and electrolyte balance, use of chem-
otherapy, and gastro-intestinal syphonage is saving
lives that would previously have been lost. Hospit^
morbidity in severe cases is cut down by the general
use of the McBurney incision, less frequent drainage
of the peritoneal cavity, and partial closure of the
wound by leaving the skin open.

10:30 IXTER>nSSIOX TO VIEW THE EXHIBITS

11:00 “Serologic Asjjects of Syphilis”

Francis E. Senear, ^I.D., Chicago

B.S., University of Michi-
gan, 1912, M.D., 1914. Pro-
fessor and Head of Depart-
ment of Dermatology, Uni-
versity of Illinois College of
Medicine since 1923. Mem-
ber of Serologic Evaluation
Committee, U. S, Public
Health Service, American
Medical Association, Chicago
Dermatological Society, So-
ciety of Investigative Der-
matology, the American
Academy of Dermatology and
Syphilology, the American
Dermatological Association.

The multiplicity of sero-
diagnostic tests for syphilis
is discussed together with a
review of the studi^ carried
out on an international and national scale in an at-
tempt to determine the best available sero-diagnostic
methods. The limitations of the diagnostic t^ts for
syphilis are discussed with a consideration of th^
phases in which the serologic reaction is apt to be
negative in the presence of disease and with a
sideration of the other disorders which are capable
of giving rise to biologic false positive ructions.
Alethods offered to distinguish between the true
svphilitic reaction and the biologic false reaction ^e
considered and their usefulness is discussed. ine
significance of positive cord blood findings is ms-
cussed and the significance of changes in the strengUi
of the reaction of the cord blood are considered.
The paradoxical false positive reactions occurnng in
individuals vdih no signs of syphilis and n°

oth°r disease to account for them are of great
significance and are met with sufiGcient
make their recognition a matter of great importance
to the practitioner.

Francis E. Senear

723

THE SEVENTY-SIXTH ANNUAL MEETING

11:30 “The Medical and Other Implications
Which Relate to An Aging Female Popula-
tion”

George W. Kosmak, M.D., New York City

A.B., M.D., Columbia Col-
lege, 1894. College of Physi-
cians and Surgeons, 1899.
Attending Surgeon, Lying-In
Hospital of New York, 1904-
1926. Editor and founder,
American Jour7tal of Obstet-
rics and Gyfiecology, 1920 to
date, editor of preceding
publication, 1909-1919. Mem-
ber, American Gynecological
Society, American Associa-
tion of Obstetricians and
Gynecologists, Diplomate of
American Board. Consultant
in obstetrics to several hos-
pitals; Federal Children's Bu-
reau, New York State De-
Geo. W. Kosmak partment of Health, etc.

Author of book, ’‘Toxemias
of Pregnancy” (1933), and of numerous articles in
medical and lay journals on obstetric topics.

It is an acknowledged fact that the average span of
life has increased from about thirty-six years in 1850
to over sixty years in 1930 and will probably reach
seventy years or more in 1960. The possible causes
for this will be discussed and attention called to the
associated medical and social problems. Undoubtedly
better economic conditions, reduced hazards to life

from improved sanitation, the lessening complications
of child-bearing, and increased medical knowledge have
constituted important contributing factors. We are
faced, however, with the question of dependence by
the older upon the younger groups and by the need of
a closer study of the degenerative diseases which are
manifest in the aged. Society and medicine must

combine to study and to solve these problems.

12:00 “The Needs and Possibilities of Research
in Mental Disease”

Lawrence Kolb, M.D., Washington

M.D., University of Mary-
land, 1908. Assistant Sur-
geon General, U. S. Public
Health Sendee, IVashington,
D. C., in charge of the Di-
vision of Mental Hygiene.
Fellow, American College of
Physicians, American Medical
Association, and American
Psychiatric Association. Mem-
ber, National Committee for
Mental Hygiene, American
Association for the Advance-
ment of Science, Research
Council on Problems of
Alcohol, Academy of Medi-
cine of Washington, D. C.,
American Prison Association,
Southern Medical Associa-
tion, Medical Society of St.
Elizabeth’s Hospital, Kentucky Psychiatric Association.
Trustee, William Alanson White Psychiatric Founda-
tion.

Recent advances in medical knowledge suggest lines
of approach to the study of the fundamental basis
of mental disease. These studies should include

biology, biochemistry, neurophysiology, pathology,

endocrinology, morphology, psychology, etc., as these
subjects may have a bearing on mental disease. Such
studies should be supplemented by extensive field
studies into the social and environmental factors.
Close cooperation between the Federal and State
governments and agencies in a position to carry on
research is needed to reap the fullest benefit from
available resources.

P. M.

12:30 End of First General Assembly
12:30 Luncheon

Lawrence Kolb

Eleven Discussion Conferences (Quiz Periods)

Eleven discussion conferences with a different chairman in each subject — leaders of outstanding ability
in their specialty. Here the doctor will have a chance to ask those questions which have bothered him and
to hear discussed and answered other questions of value to him in his daily practice.

September 17 — 3:30 to 4:30 p.m.

MEDICINE

OBSTETTRICS AND

PEDIATRICS

SURGERY

SYPHILOLOGY

anesthesia

Ballroom, Pantlind

GYNECOLOGY

Red Room, Civic

Black and Silver

Room “F,” Civic

Room “G,” Civic

Hotel

Grill Room, Pantlind
Hotel

Auditorium

Ballroom, Civic
Auditorium

Auditorium

Auditorium

Leader:

E. D. Spalding,

Leader :

Leader:

Leader:

Leader:

Leader :

M.D.

W. F. Seeley, M.D.

C. F. McKhann,
M D

F. A. CoLLER, M.D.

R. C. Jamieson,

F. J. Murphy, M.D.

Detroit

Detroit

Ann Arbor

Ann Arbor
Guest Conferees:

M.D.

Detroit

Detroit

R. L. Cecil, M.D.

Guest Conferee:

Guest Conferee :

E. C. Cutler, M.D.

Guest Conferee :

Guest Conferee:

New York City

George Kosmak,

Henry Poncher,

Boston

Wesley Bourns,

L. Kolb, M.D.

M.D.

M.D.

A. J. Lanza, M.D.

F. E. Senear, M.D.

M.D.

Washington, U. C.

New York City

Chicago

New York City

Chicago

Montreal

September 18 — 3:30 to 4:30 p.m.

MEDICINE
Ballroom, Pantlind
Hotel

Leader :

C. C. Sturgis, M.D.
Ann Arbor

Guest Conferees :

C. E. Lyght, M.D.

Northfield, Minn.

V. P. Sydenstricker,
M.D.

Atlanta, Ga.

C. S. Keefer, M.D.
Boston

OBSTETRICS AND

PEDIATRICS

OPHTHAL-

PATHOLOGY

GYNECOLOGY

MOLOGY

Room “F,” Civic
Auditorium

Grill Room, Pantlind
Hotel

Red Room, Civic
Auditorium

Black and Silver
Ballroom, Civic

Leader :

Auditorium

Leader:

N. F. Miller, M.D.

Leader:

Osborne A. Brines,

Ann Arbor

J. L. Wilson, M.D.

Leader:

M.D.

Guest Conferees:

Detroit

Parker Heath, M.D.
Detroit

Guest Conferee :

Detroit

J. R. McCord, M.D.
Atlanta, Ga.

W. F. Mengert,

Guest Conferee:

Guest Conferee :
Shields Warren,

M.D.

James Gamble, M.D.

Alfred Cowan, M.D.

M.D.

Iowa City, Iowa

Boston

Philadelphia

Boston

All Members Are Invited to Participate

Join in These

Quiz

Periods

with the

Guest

Essayists

724

Jour. M.S.M.S.

THE SEVENTY-SIXTH ANNUAL MEETING

WEDNESDAY AFTERNOON
September 17, 1941

Second General Assembly

Black and Silver Ballroom — Civic Auditorium

Verxor ;M. Moore, M.D., Presiding
L. Fernald Foster, M.D., and Robert G. Laird, M.D.,
Secretaries

P. M.

1:30 Officiis in Anesthesia”

Wesley Bourxe, M.D., ^lontreal

M.D., CM., McGill Uni-
versity, 1911; M.Sc., McGill,
1924; F.R.C.P., Canada,

1931; D.A. (R.C.P. & S.
Eng.), 1938. First Hickman
Medallist, Roy. Soc. of Medi-
cine, 1935. Lieutenant-Colo-
nel, R.C.A.M.C. Lecturer
(Anesthesia) Department of
Pharmacology, McGill Uni-
versity. Author of many
p-ublications on anesthesia.
Member of the American
Society for Pharmacology
and Experimental Therapeu-
tics.

Although duties prescribed
by justice are to be given
precedence, and nothing
ought to be more sacred, yet
in the pursuit of knowledge, we should feel obliged
to apply our wisdom to the service of humanity. We
ought to consider ourselves bound to teach and train
those who are desirous of learning. In such manner
the benefits of anesthesia may be extended to those
with whom we are united by the bonds of society.
With increasing concerted effort, by cooperation
between the laboratory worker and the clinician,
anesthesia has improved, and the public is recognizing
the need and importance of good anesthesia.

Weslzy Bourne

2:00 “Medical Service in Small Industries”

A. J. Lanza, M.D., New York City

^M.D., George Washington
University Medical School,
1906. Served in the United
States Public Health Service
from 1907 until 1920. During
part of this time ivas detailed
as Chief Surgeon of the
United States Bureau of
Mines, and later. Head of
the Office of Occupation^
Diseases in the Public Health
Service. Mostly engaged in
Field veork doing investiga-
tions in industrial hygiene.
Conducted the first studies in
this country on silicosis.
1920 became Medical Director
of the Hydraulic Steel Com-
A. J. Lanza pany of Cleveland. In 1921

was appointed a special Staff
member of the International Health Board of the
Rockefeller Foundation, and was detailed as Adviser
in industrial hygiene for the Commonwealth Govern-
ment of Australia. In 1926 was appointed Assistant
Medical Director of the Metropolitan Life Insurance
Company. At present time is a member of the
. Council of the American Medical Association on

Industrial Health. Member of the Sub-committee on
Industrial Health of the Health and Medical Com-
mittee, Federal Security Agency. Chairman of the
Medical Committee of the Air Hygiene Foundation.

The great bulk of all wage earners are employed
in small plants, and 97 per cent of all manufacturing
plants employ fewer than 250 men. The problem of
providing adequate medical and health service for
American wage earners is, therefore, essentially a
problem of devising a program that will fit the small

September, 1941

industry. WTiile occupational d.iseases are a definite
factor in the industrial health situation, the loss in
working days is due to non-occupational hazards. The
American Medical Association, State Medical Societies
and other Medical Organizations, axe taking cognizance
of this problem, as well as official agencies, like the
Public Health Service, and non-official agencies, such
as the Air Hygiene Foundation. It is obvious that
health and medical service in these small plants, where
the majority of American workmen are employed,
will be given by local physicians serving industry on
a part-time basis. Here is an opporttmity, and the
responsibility of the medical profession. The difference
between medical service in a small plant and in a
large one should be a difference in quantity only,
and not in quality. Then, if only a small reduction
can be made in absences in industry, it will never-
thele^ accompany a great economic saving and be a
contribution of inestimable value with the production
problem that faces Americail industry at the present
time.

ACKNOWLEDGMENT: The >Iichigan Department

of Health is sincerely thanked for its sponsor-
ship of this lecture.

2:30 ES TER>nSSION TO ATEW THE EXHIBITS

3:00 “Hemorrhage in the Newborn”
Henry Poncher, !M.D., Chicago

M.D.. University of Mich-
igan, 1927, Associate Pro-
fessor of Pediatrics, College
of Medicine, University of
Illinois, Attending Physician,
Cook County Hospital, Physi-
cian in charge of Pediatric
Service, Research and Edu-
cational Hospitals of Illinois.
Licentiate of American Board
of Pediatrics.

The newborn may po-

tentially hemorrhage from a
variety of causes. Practically,
however, trauma alone or

minimal trauma in the pres-
ence of a disturbed clotting
mechanism are the ones that
Henry Poncher the practicing physician en-
counters most commonly in
his daily work. The minimizing of the traumatic

factor alone is outside the scope of this presentation.
The part that disturbed coagulability of the blo(^

plays in conditioning hemorrhage of traiunatic origin
or giving rise to spontaneous bleeding will be dis-
cussed. The recent work on prothrombin and vitamin
K will be reviewed from the standpoint of its
practical implications.

3:30 DISCrSSION CONFERENCES WITH
GEEST ESSAYISTS. (See Page 724.)

5:00 End of Second General Assembly

MSMS

You will find every meeting held at the saine
building, which has a seating capacity of 5,700 in its
main auditorium besides numerous smaller rooms,
while attending the Annual Meeting of the Michi-
gan State Medical Society, September 17, 18, and
19 at Grand Rapids.

MSMS-

The President’s Night will be a gala affair. Na-
tionally known speakers and a complete program
of outstanding entertainers await you at the An-
nual Meeting of the Michigan State Meiffcal Society,
September 17, 18, and 19 at Grand Rapids.

725

THE SEVENTY-SIXTH ANNUAL MEETING

WEDNESDAY EVENING
September 17, 1941

Third General Assembly

— Public Meeting —

Ballroom, Pantlind Hotel

Paul R. Urmston, M.D., Presiding
L. Fernald Foster, M.D., Secretary

PRESIDENT’S NIGHT
8:30 P.M.

1. Call to order by President Paul R. Urmston,

M.D.

2. Annoimoements and Reports of the House of
Delegates, by Secretary U. Femald Foster,
M.D., Bay City

3. “The Physician in National Defense”

Robert A. Bier, Major, Medical Corps, National
Headquarters, Selective Service System, Washing-
ton, D. C.

4. President’s Annual Address — Paul R. Urm-
ston, M.D., Bay City

5. Presentation of Scroll and Past President’s
Key to Doctor Urmston by A. S. Brunk, M.D.,
Chairman of The Council

6. Induction of Henry R. Carstens, M.D., Detroit,
into office as President of the Michigan State
Medical Society.

Response.

7. Introduction of the President-Elect and other
newly elected officers of the State Society.

9:00 P.M.

8. The Andrew P. Biddle Oration:

“The Code of Medical Ethics”

Alphonse Schwitalla, SJ., St. Louis, Mo.

THURSDAY MORNING
September 18, 1941

Fourth General Assembly

Black and Silver Ballroom — Civic Auditorium

C. E. Umphrey, M.D., Presiding,

L. Fernald Foster, M.D., and Gordon B. Myers, M.D.,
Secretaries

A. M.

9:30 “Some Obstetric Opinions”

James R. McCord, M.D., Atlanta

M.D., Jefferson Medical
College, 1909; Professor of
Obstetrics and Gynecology,
iZwory School of Medicine ;
Diplomate American Board of
Obstetrics and Gynecology.

The paper is, in the main,
an expression of the author’s
own personal philosophy of
obstetrics and a brief dis-
cussion concerning the
management of quite a few
obstetric difficulties. Practi-
cally all of the opinions are
personal and have as their
background Dr. McCord’s
vast obstetric experience.

James R. McCord

ACKNOWLEDGMENT: The W. K. Kellogg Foun-

dation is sincerely thanked for its sponsorship of
this lecture.

10:00 “Some Educational Aspects of Diagnosing
Tuberculosis Early”

Charles E. Lyght, M.D., Northfield, Minn.

A.M., St. Louis University,
1908; Ph.D., Johns Hopkins
University (Zoology), 1921;
LL.D., Tiilane University,
New Orleans, 1938; Sc.D.,
I^awrencc College, 1939.
Dean, St. Louis University
School of Medicine; Regent,
St. Louis University School
of Nursing and School of
Dentistry; President, Cath-
olic Hospital Association of
U. S. and Canada; Professor
of Biology and Director of
the Department, St. Louis
University; Past President,
North Central Association of
A. Schwitalla, S.J. Colleges and Secondary
Schools; Editor of HOSPl-
I AL PROGRESS; Associate Felloiv, American Medi-
cal Association.

The code of medical ethics has recently been the
object of attack from various sources. During the
trial of the American Medical Association, its pro-
visions were subjected to criticism and in the case
of at least one witness, to ridicule. It was repeatedly
suggested that the code was in practice merely a
figment to be used as a cloak for covering the
physician’s self-interests. The differentiation between
a profession and a trade in so far as that differentia-
tion rests upon the idealism and the exactions of a
code of ethics, has been seriously called into ques-
tion. For this reason, the origin, the provisions, the
philosophy and the applications of the code of medical
ethics deserve special study and attention not only
by the public but also by physicians so that the
latter may be able more fully to penetrate into the
basis upon which rest their claims to professional
standing and so that the validity of the concept of a
profession might be more emphatically reaffirmed.

9. Presentation of Biddle Oration Scroll
10:00 P.M.

Entertainment and Dancing

M.D., C.M., Queen’s Uni-
versity Faculty of Medicine,
(Canada), 1926. Department
of Student Health, Uni-
versity of Wisconsin, Madi-
son, 1927-36; Director, 1932-
36; Associate Professor of
Clinical Medicine, University
of Wisconsin Medical School.
Professor of Health and
Physical Education, and
Director of the Student
Health Service, Carleton
College, Northfield, Minne-
sota, 1936 to date. Staff
of Northfield City Hospit^
and Allen Memorial In-
firmary. Fellow of the
Charles E. Lyght American College of Physi-
cians. Member of several
professional and scientific societies, including the
Minnesota Trudeau Medical Society and Stgma Xu
Past President of the North Central Section, American
Student Health Association, and, since 1936,
man of the Tuberculosis Convmittee, A.S.H.A.
Publications, in addition to a weekly column: “Lyght
on Health," have been mainly in the fields of clinical
medicine, tuberculosis control and student health.

Prognosis in tuberculosis depends on a combination
o^ factors, chief favorable one being early diagriosis.
Mass search has produced startling results in driving
tuberculosis from first down to seventh among death
causes. Individual practitioners must not decide that
modern methods work only in community surveys or
are the implements of specialists. Nor must we
strengthen techniques only during periodic national
emergencies. Tuberculin test, x-ray,_ with painstaking
clinical, laboratory and epidemiological follow-up of
patients and contacts are available to every physician.
To wait for consumptive symptoms or to rely primarily
on the stethoscope is to diagnose late — inexcusable in
the light of common knowledge and professional
obligation.

ACKNOWLEDGMENT: The Michigan Tubercu-

losis Association is sincerely thanked for its
sponsorship of this lecture.

726

Jour. M.S.M.S.

THE SEVENTY-SIXTH ANNUAL MEETING

10:30 INTERMISSION TO VIEW THE EXHIBITS

11:00 “Factors in Deficiency Disease”

V. P. Sydenstricker, M.D., Augusta, Ga.

P. M.

12:00 “THE DIAGNOSIS AND TREATMENT OF
PLACENTA PREVIA”

William F. Mengert, M.D., Iowa City, Iowa

M.D., Johns Hopkins, 1915. Intern and assistant
resident physician, Johns Hopkins Hospital, 1915-17.
Medical Corps, U. S. Army, 1917-19. Professor of
Medicine, University of Georgia School of Medicine,
1923 to present. .

The background of clinical avitaminoses will be dis-
cussed from the standpoint of dietary inadequacy and
also of conditioning disorders in individuals taking
apparently adequate diets. Various clinical patterns
of deficiency diseases will be presented with particu-
lar reference to the more common but often unrecog-
nized syndromes. The rationale of treatment of both
the acute and chronic deficiency diseases will be con-
sidered, with particular emphasis on the importance of
multiple vitamin therapy.

11:30 “Pathogenesis of Acidosis and Alkalosis”

James L. Gamble, M.D., Boston

A.B., Leland Stanford
University, 1906, M.D.,

Harvard Medical School,
1910, S. M. (hon.) Yale Uni-
versity, 1930. Teaching and
investigation in Department
of Pediatrics, The Harvard
Medical School (1915-22).
Professor of Pediatrics, 1930
to date. Member American
Pediatric Society, American
Academy of Pediatrics, As-
sociation of American Physi-
cians, American Society of
Biological Chemists.

Stability of the reaction of
extracellular fluid depends on
preservation of the normal
values for carbonic acid and
bicarbonate. Acidosis, or
alkalosis, is almost always the result of change in
bicarbonate rather than carbonic acid. Change in
bicarbonate is always the result of change iri other
parts of the electrolyte structure. _ Illustration of
such change caused by various conditions of disease
is presented. The very frequent presence _ of volume
change (dehydration) along with change in reaction
is emphasized.

-MSMS-

James L. Gamble

Wm. F. Mengert

M.D.. Johns Hopkins Med-
ical School, 1927; Diplomate,
National Board of Medical
Examiners, 1928; Rotating
Intern, University of Iowa
Hospitals, 1927-28; succes-
sively, departmental intern
(1 yr.), assistant (1 yr) and
instructor (2 yrs.) in the De-
partment of Obstetrics and
Gynecology, University of
Iowa, 1928-32. Fellow in
Gynecologic _ Research, Gyne-
cean Hospital Institute of
Gynecologic Research, Uni-
versity of Pennsylvania,
1932-34; Assistant Professor
of Obstetrics and Gynecol-
ogy, University of Iowa,

1934-38; Associate Professor from 1938 to date. As-
sociate Obstetrician and Gynecologist to the Univer-
sity Hospitals since 1934. Diplomate of the American
Board of Obstetrics and Gynecology 1933. Member
and officer of numerous medical brganieations as well
as fraternal and social groups. Author of several
medical articles.

The incidence of placenta previa among 14,569

deliveries at the University of Iowa was 1 : 198.

Sterile vaginal examination represents the only cer-
tain method of diagnosis. Bladder cystograms are a
dia^ostic aid, and their technique is discussed. Insti-
tution of some method of delivery should generally
follow the establishment of the diagnosis. The

choice of the method varies, but manual dilation
of the cervix has no place in the treatment. Vaginal
packing and Braxton Hicks version should be em-
ployed only when other facilities are not available.
The fetal mortality rate is always high, but the
mother can usually be saved by prompt, energetic

and appropriate treatment, of which the most impor-
tant single factor is blood transfusion.

12:30 End of Fourth General Assembly
12:30 Luncheon

MSIMS

When you attend the Section on Dermatology and
Syphilology which meets Friday morning, September
19, in connection with the Annual Meeting of the
Michigan State Medical Society, Carroll S. Wright,
M.D., of Philadelphia, will tell you of some of the
spectacular results which can be obtained in some
skin diseases by judicious administration of the
various factors of Vitamin B.

■MSMS-

The hotels will make every effort to care for you
satisfactorily when you come to the Annual Meeting
of the Michigan State Medical Society, September
17, 18, and 19 at Grand Rapids.

MSMS-

A metropolitan population of 209,535 welcomes you
to the Annual Meeting of the Michigan State Med-
ical Society, September 17, 18, and 19 at Grand
Rapids.

September, 1941

WHAT'S THEIR HURRY?

They're rushing to the MSMS Convention
"Smoker," Thursday evening, September 18,
Ballroom, Pantlind Hotel. Grand Rapids.

727

THE SEVENTY-SIXTH ANNUAL MEETING

THURSDAY AFTERNOON
September 18, 1941

Fifth General Assembly

supporting tissues, and the effect on the normal issues
of the host. Depending on their response to radiation
tumors _ may be classed as radio-sensitive, radio-
responsive, and radio-resistant. Radio-resistance may
be acquired following radiation therapy.

The tissue reactions for a given dose are fairly
constant and characteristic regardless of minor varia-
tions in wave length. Recently irradiated tissue is
very susceptible to infection.

Black and Silver Ballroom — Civic Auditorium 2:30 INTERMISSION TO V^EEW THE EXHIBITS

Wilfrid Haughey, M.D., Presiding
L. Fernald Foster, M.D., and Frank Murphy, M.D.,
Secretaries

P. M.

1:30 “Some Observations on the Use of Glasses”
Alfred Cowan, M.D., Philadelphia

M.D., Medico Chirurgical
College, Philadelphia, 1907.
At present Professor of
Ophthalmic Optics, Graduate
School of Medicine, Uni-
versity of Pennsylvania;
Ophthalmologist to Phila-
delphia General Hospital;
Supervising Opthalmologist,
Department of Public As-
sistance, Commonwealth of
Pennsylvania; Consulting
Ophthalmologist, Council for
the Blind, Commonwealth of
Pennsylvania; Ophthalmol-
ogist to Pennsylvania Work-
ing Home for Blind Men,
Philadelphia; Author of “An
Alfred Cowan Introductory Course in Oph-
thalmic Optics” and of “Re-
fraction of the Eye,” and a number of articles on
ophthalmological subjects; a member of the American
Ophthalmological Society; American Academy of
Ophthalmology and Otolaryngology ; College of Physi-
cians, Philadelphia, and others.

.3:00 “Recent Advances in Chemotherapy of In-
fectious Diseases”

Chester S. Keefer, M.D., Boston

M.D., Johns Hopkins Uni-
versity School of Medicine,
1922; Director, Evans Me-
morial, Massachusetts Me-
mo-rial Hospitals; Wade Pro-
fessor of Medicine, Boston
University School of Medi-
cine; Diplomate, American
Board Internal Medicine.

The treatment of infectious ,
diseases with the sulfonamide
group has advanced remark-
ably in the past few years.
New compounds are being 1
developed and tested every
year so that there are at
least five effective agents
available at present. Each J
one of these sulfonamide derivatives has its special '
field of usefulness, and will be discussed in this paper. )
One recent study with sulfadiazine and sulfaguanidine •
will be presented. In addition to the discussion of the ’
sulfonamides, our experience in the treatment of local
infections with “gramicidin,” the extract of a soil 1
bacillus, will be reviewed. i'

Chester S. Keefer

3:30 DISCUSSION CONFERENCES WITH'
GUEST ESSAYISTS. (See Page 724.)

This presentation isi offered with the hope that it
will suggest to the general physician a simple way
of describing certain physiologic optical principles to
their patients — the purposes for which glasses are
used, when they should be worn and when they are
not worthwhile.

The normal eye is an image-forming optical instru-
ment with a remarkable range of adaptability. Qear,
comfortable vision depends primarily on a sharp
image which must be formed exactly on the surface
of the retina without undue effort of accommodation.
In a refractive error — myopia, hypermetropia, as-
tigruatism — the correct lens, when placed before the
eye, changes the final direction o.f the rays of light
so that on entering the eye they will be imaged on
the retina. This is equivalent to placing an object at
the exact position for which the eye is adapted.

A refractive error is not a disease, nor can it be
produced by working under unfavorable conditions.
Every person must eventually become presbyopic.

2:00 “The Resjxmse of Tmnors to Radiation”

Shields Warren, M.D., Boston

5:00 End of Fifth General Assembly

MSMS

THURSDAY EVENING
September 18, 1941

Sixth General Assembly

(For M.S.M.S. Members Only)

Ballroom, Pantlind Hotel

Grover C. Penberthy, M.D., Detroit, Presiding
L. Fernald Foster, M.D., Secretary

Shields Warren

B.S., Boston University ;
M.D., Harvard Medical
School, 1923; Assistant Pro-
fessor of Pathology, Harvard
Medical School, 1936 to
date; Director, Massachusetts
State Tumor Diagnosis Serv-
ice, 1928 to date; Pathologist
to New England Deaconess
Hospital, 1927 to date, C. P.
Huntington Memorial Hospi-
tal, 1928 to date. New Eng-
land Baptist Hospital, 1928
to date, Pondville State
Hospital, 1928 to date; Chair-
man, Cancer Committee,
Massachusetts Medical Soci-
ety; Vice President, Ameri-
ca7i Association for Cancer
Research.

1

SMOKER 1

Admission by Card Only
Nine O’ Clock

Refreshments

Music and Entertaimnent

Host: The Michigan State Medical Society

728

The response oif tumors to radiation is based on
the sensitivity of the type cell, the character of the

Tour. M.S.M.S.

I

I

' THE SEVENTY-SIXTH ANNUAL MEETING

PROGRAM of SECTIONS

FRIDAY MORNING
September 19, 1941

SECTION OX GEXERALi MEDICINE

Chairman: T. I. Bauer, M.D., Lansing
Secretary: Gorikdn B. Myers, M.D., Detroit

Ballroom — PantJind Hotel

A. M.

9:00 “The Differential Diagnosis of Abdominal
Pain”

Milton R. Weed, M.D., Detroit

9:30 “The Differentiation Between Malignant
and Benign Ulcerating liesions of the Stom-
ach”

H. M. Pollard, M.D., Ann Arbor
Wm. C. Scott, M.D., Ann Arbor

10:00 “Problems in the Differential Diagnosis of
Coronary Artery Disease”

A. R. Barnes, AI.D., Rochester, Minnesota

M.D., Indiana University
School of Medicine, 1919;
Professor of Medicine, Mayo
Foundation for Medical Edu-
cation and Research, Uni-
versity of Minnesota, and
Chief of a Section in Medi-
cine, The Mayo Clinic,
Rochester, Minnesota; Diplo-
niate, American Board of
Internal Medicine.

So much has been said and
written on the subject of
coronary sclerosis that there
is some evidence of a tenden-
cy to make the diagnosis
more frequently than the
facts warrant. Unfortunately,
the syndrome of angina pec-
toris is a diagnosis that has
to be made on the basis of the patient’s symptoms
and much skill and experience is required in arriving
at the dia^osis. There is a tendericy to allow the
electro-cardiogram to influence this diagnosis, unduly.
There are other clinical conditions, such as peri-
carditis, pulmonary embolism, cholecystic disease and
diaphragmatic hernia, which may simulate the pain
of coronary artery disease very closely. _ This dis-
cussion will concern itself with the essential cliniMl
features of coronary disease and _ its differential
diagnosis from the clinical conditions mentioned.

10:30 “Clinical Use of the Diuretics”

Richard H. Lyons, M.D., Eloise

11:00 “Treatment of Pyelonephritis”

Muir Clapper, M.D., Detroit

11:30 “Useful Drugs in the Treatment of
Asthma”

John M. Sheldon, M.D., Ann Arbor

12:00 Election of Officers

SECTION ON SUTIGERY

Chairman : O. H. Gillett, M.D., Grand Rapids
Secretaiy- : Roger Y. Walker, M.D., Detroit

Black and Silver Ballroom — Civic Auditorium
8:30 A. M.

SY^IPOSIUM ON TRAU>L\TIC SURGERY^
“Management of Skull Fractures”

Harry E. AIock, AI.D., Chicago

M.D., Rush Medical Col-
lege, 1906. Associate Pro-
fessor of Surgery North-
western University Medical
School; Senior Surgeon St.
Lukes Hospital, Chicago;
Fellow American Board of
Surgery, American College of
Surgeons; Chicago Surgical
Society; Chicago Institute of
Medicine; American Associa-
tion of Surgery of Trauma,
and others. Author of many
.surgical subjects. Exhibitor
in the Scientific Exhibits of
the American Medical As-
sociation from 1931 to 1938
on the subject of Skull
Fractures and Craniocerebral
Injuries.

Craniocerebral injuries in the United States occur
to the extent of more than half a million victims a
year. Approximately 65 per cent of the deaths
resulting from skull fractures occur in the first
twenty-four hours following the injury. The wide-
spread distribution and the early occurence of death
will always make this a problem for the general
physician and surgeon. The author collected and
analyzed 3,300 cases of consecutive proved skull
fractures from 1929 through 1934. The mortality rate
varied from 25 per cent to 49 per cent during that
period. The last ten years has brought forth abundant
teaching of better management. Has it reduced the
mortality rate? Is there room for still further im-
provement? These and other questions are answered
in the author’s second nation-wide survey of 3,200
consecutive proved skull fractures.

“Uacerations of the Head and Face”

Ferris N. Smith, AI.D., Grand Rapids

“Choice of Anesthesia in Emergency
Surgery”

Wesley Bourne, M.D., Alontreal

(Biography on Page 725)

The general principles of anesthesia are not affected
by the circumstances of emergency, yet the individual
may frequently be most urgently in need of the
best attention known to anesthesia. WTiatever is done
should suit the general condition as well as the
surgical requirements of the case. When shock _ is
present, there must be the greatest circumspection
and the least possible interference imtil the circulation
is improved. The relative advantages of the drugs
and the methods of their administration are discussed
under the groupings of regional and general anesthesia,
showing the appropriate places of local infiltration,
of nerve block and of spinal anesthesia, and too, those
for inhalation and intravenous anesthesia.

“Early Care of Compound Fractures”

Carl E. Badgley, M.D., Ann Arbor
“Management of Abdominal Injuries”
Owen H. Wangensteen, M.D., Minneapolis
(Biography on Page 724.)

World War Number Two has focused attention
upon the subject of trauma sharply again. WTiereas
the mortality of abdominal injuries in war has always
been high, statistically, the incidence of abdomiiial
injuries, as compared with the more frequent injuries
of extremities and head, has not been great. World
War Number One settled, once and_ for all, the
importance of early closure of perforating wounds of
the hollow abdominal viscera. Theretofore, the con-
servative management of bullet wounds of the intestine
had been advocated by many military surgeons.

Habry E. Mock

September, 1941

729

THE SEVENTY-SIXTH ANNUAL MEETING

1

Despite general acceptance of early operative treat-
ment, the mortality still continues high, because of
the serious threat to life, occasioned by spillage of
intestinal content into the peritoneal cavity.

In civil practice, one of the greatest difficulties
is determination of whether or not blunt trauma has
ruptured a hollow viscus. Tears in solid viscera,

' such as liver or spleen, may be treated conservatively,

if hemorrhage is not alarming. Bleeding stops fre-
quently spontaneously. Ruptures of hollow viscera
must be closed if the oatient is to have a chance of
survival.

“Treatment of Shock from War Injuries”

Henry N. Harkins, M.D., Detroit

Election of Officers

MSMS

SECTION ON OBSTETRICS AND GYNECOLOGY

Chairman : Clair E. Folsome, M.D., Ann Arbor
Secretary: Robert S. Kennedy, M.D., Detroit

Grill Room — Pantlind Hotel

A. M.

9:30 “Facilities and Practices in Licensed Ma^
temity Hospital and Maternity Homes in
Michigan”

Alexander M. Campbell, M.D., Grand Rapids

9:50 “The Use and Abuse of Stilbesterol in
Gynecologic Practice”

Allan C. Barnes, M.D., Ann Arbor

10:10 “Review of Certain Criteria Possibly Useful
in the Differential Diagnosis of the Tox-
emias of Pregnancy”

Palmer E. Sutton, Ad.D., Royal Oak

10:30 “The Dangers of Breech Delivery”

Ward F. Seeley, M.D., Detroit
R. S. SiDDALL, M.D., Detroit

11:00 “Therapy of the Estrogens”

Richard W. TeLinde, M.D., Baltimore

A.B., University of Wis-
consin. 1917. M.D.. Johns

Hopkins University, 1920.
Professor of Gynecology,
Johns Hopkins University.
Chief Gynecologist, Johns
Hopkms Hospital. Visiting
Gynecologist, Union Memo-
rial Hospital, Church Home
and Infirmary and Hospital
for Women of Maryland.

Attention is called to the
many abuses in endocrine

therapy in general and a
warning is given to use
hormones only when there is
a sound physiological basis
for treatment. The results
Richard W. TeLindb at the author’s clinic in the
treatment of certain condi-
tions in which he has had special experience are
considered. The technique of the treatment of
gonococcal vaginitis with estrogenic suppositories, both
natural and synthetic, is discussed. The treatment
of menopausal symptoms by the natural hormones

and stilbestrol is considered. Finally, a new technique
for the administration of pellets of crystalline estrone
for prolonged relief of menopausal symptoms is

given in detail.

11:30 Election of Officers

12:00 Limcheon

730

SECTION ON OPHTHALMOLOGY AND
OTOLARYNGOLOGY

Chairman: Robert H. Fraser, M.D., Battle Creek
Vice Chairman: A. S. Barr, M.D., Ann Arbor
Secretary: Robert G. Laird, M.D., Grand Rapids
Vice Secretary: Arthur E. Hammond, M.D., Detroit

OPHTHALMOLOGY
Room “F” — Civic Auditorium

A. M.

9:30 “Uveitis” i

Alfred Cowan, M.D., Philadelphia
(Biography on Page 728)

The various parts of the uveal tract . are so inti-
mately related that hardly, if ever, is any one part
affected without involvement of all or nearly all of
the whole tract. More and more, since the general
use of the slit lamp and corneal microscope, is this
observed; so much so that specific diagnoses as
iritis, cyclitis, or irido cyclitis are seldom well justi-
fied. The first evidence of any insult to the iris or
ciliary body is a disturbance of the pigment. Often
we see evidence of uveal change, especially disturb-
ance of the pigment, which is hard to classify as
either a noninflammatory degenerative process or a
low grade, chronic uveitis. The etiologic factors
in these cases are nearly always baffling. So fre-
quently do we see such conditions that it is felt
that many which are diagnosed as primary glaucoma
are in reality cases of uveitis with secondary glau-
coma.

10:10 Discussion — ^20 Minutes
10:30 “Dendritic Keratitis”

John O. Wetzel, M.D., Lansing
10:50 Discussion — 10 Minutes

11:00 “Management of Traumatic Injuries to the
Eyelids and Globe”

Gordon L. Witter, M.D., Port Huron

11:20 Discussion — 10 Minutes

11:30 “Chemical Injuries”

Melvin H. Pike, M.D., Midland

11:50 Discussion — 10 Minutes

12:00 “Some Uses of Chemotherapy in Ophthal-
mology”

P.\rker Heath, M.D., Detroit

P. M.

12:20 Discussion — 10 Minutes

OTOLARYNGOLOGY
Room “G” — Civic Auditorium

A. M.

9:00 “Mistakes Made in the Diagnosis and Esti-
mation of Deafness”

D. E. S. WiSHART, M.D., Toronto, Ontario
(Biography on Page 723)

There were universally accepted routine hearing
tests. At present there_ is no universally accepted
routine hearing examination.

The old tests weie unreliable. The new tests are
still unreliable.

Tuning forks are relatively inexpensive. How they

Jour. M.S.M.S.

THE SEVENTY-SIXTH ANNUAL MEETING

can still be used to give accurate information — but
the amount given is very limited.

Audiometers — the new electrical instruments — are
not standardized and are still unreliable.

Common errors in audiometry. What information
can be obtained by the use of audiometers?

The audiometer has shown how inaccurate hearing
testing has been and is.

The diagnosis of deafness will never be easy.

9:30 Discussion — 10 Minutes

9:40 “Acute Suppuration in the Spaces of the
Neck” and Motion Picture Demonstration:
“Approaches to the Surgical Spaces of the
Neck.”

Samuel Iglauer, M.D., Cincinnati

M.D., Ohio Medical Col-
lege, 1898; F.A.C.S.; Profes-
sor of Otolaryngology, Col-
lege of Medicine, University
of Cincinnati; Director of
Otolaryngology, Cincinnati
General Hospital, Children’s
Hospital, and Jeivish Hos-
pital; member, American
Laryngological, Rhinological,
and Otological Society,
American Broncho-Esophago-
lo-gical Assn., American
Laryngological Assn., Ameri-
can Academy of Ophthalmol-
ogy and Otolaryngology.

During recent years a
great deal of exact attention
Samuel Iglauer has been given to deep in-
fections in the neck. These
infectious processes may localize in the lymph glands,
in the “spaces” of the neck, or occasionally within
the veins. The anatomic spaces contain loose dis-
tensible areolar connective tissue. The spaces are
limited by tough, fibro'us layers (fascia) or by
muscles or viscera The spaces most commonly in-
volved are: 1. Peripharyngeal; 2. Retropharyngeal;
3. Parapharyngeal (Pharyngo-maxillary) ; 4. Perie-
sophageal (Mediastinitis) ; 5. Submental (Ludwig’s

Angina) ; 6. Septic thrombophlebitis (jugular) may

occur as a complication.

The signs and symptoms of infection in each space
will be enumerated, and the surgical approach to
each space will be briefly described.

Discussion and Bibliography Question Box
(by request)

11:30 “Carcinoma of the Mastoid. Case report”
Harvey E. Dowling, M.D., Detroit

11:50 “Treatment of Hemorrhage in Otolaryn-
gologic Practice”

James E. Croushore, M.D., Detroit

P. M.

12:10 Discussion of papers by Drs. Dowling and
Croushore

12:30 Section Dimcheon, Pantlind Hotel

Election of Officers of Section on
Ophthalmology and Otolaryngology
Short Business and Medical Economics
Session.

“Problems of Distribution of Ophthalmo-
logic Care”

Ralph H. Pino, M.D., Detroit
^MSMS

Thirty of the foremost out-of-state medical au-
thorities will speak at the Annual Meeting of the

Michigan State Medical Society, September 17, 18,

and 19 at Grand Rapids.

September, 1941

SECTION ON PEDIATRICS

Chairman: Harry A. Towsley, M.D., Ann Arbor
Secretary: Leon DeVel, M.D., Grand Rapids

SwTss Room — ^Pantlind Hotel

A. M.

9:00 Case Report: “Tumor of Adrenal Cortex in
an Infant of Seventeen Months” Color
Photography and Autopsy Findings

Rockwell M. Kempton, M.D., Saginaw
Oliver W. Lohr, M.D., Saginaw

9:15 Panel Discussion: “Diarrhea in Infancy”

Chairman— Charles F. McKhann, M.D., Ann
Arbor

Discussants — James L. Wilson, M.D., Detroit
A. Morgan Hill, M.D., Grand Rapids
Wyman C. C. Cole, M.D., Detroit
Mark' Osterlin, M.D., Traverse City
Warren Wheeler, M.D., Detroit

11:15 “Cerebral Atrophy in Infants and Children”

Harold K. Faber, M.D., San Francisco

A.B., Harvard College,
1906; M.D., University of
Michigan, 1911. Professor
of Pediatrics, Stanford Uni-
versity School of Medicine;
Pediatrician-in-Chief, Stan-
ford University Hospitais,
San _ Francisco. Member:
American Pediatric Society,
American Academy of Pedia-
trics, Society for Pediatric
Research, et cetera.

The causes of mental de-
ficiency, spastic diplegia and
convulsive disorders long ob-
scure, have been clarified for
a considerable percentage of
cases by consideration of the
effects of anoxia on the
brain and by studies of the
air encephalogram. Heredity is now found to play
a much smaller part than had been previously sup-
posed, and the same is true of intracranial hemor-
rhage at birth. It is, however, a mistake to believe
that all cases date from the time of birth. Both
fetal and postnatal disorders are of etiological im-
portance. A series of cases is reviewed in which
the causative factors are discussed. Some preventive
suggestions are presented.

12:00 Business Meeting — ^Election of Officers

-MSMS-

SECTION ON DERMATOLOGY AND
SYPHELOLOGY

Chairman : Cl.vud Behn, M.D., Detroit

Secretary: Frank Stiles, M.D., Lansing

Directors’ Room— Civic Auditorium

A. M.

9:30 “Therapeutic Effects of Vitamin B Factors
in Dermatology”

Carroll S. Wright, M.D., Philadelphia
(Biography on Page 733)

The various factors of Vitamin B are of more
than ordinary intrest to the dermatologist. Vitamin
Bi is noiw widely used to relieve the pain of herpes
zoster and there is some evidence that it may be
helpful in psoriasis. The spectacular improvement
in _ pellagrins following the administration of nicotinic
acid is now fully recognized. Riboflavin cures
cheilosis, erosions around the eyes, “sharkskin”
lesions of the skin over the nose and may be
helpful in Assuring around the ears. It also in-

Harold K. Faber

731

THE SEVENTY-SIXTH ANNUAL MEETING

creases the efficacy of nicotinic acid in certain
pellagrins (Spies). The filtrate factor (pantothenic
acid) is probably not concerned in pellagra. Interest
centers in its anti-gray hair action. Vitamin Be
(pyrodoxine hydrochloride), often called the “rat
anti-dermatitis factor” is known to have a definite
action in the treatment of pellagra. This study is
concerned chiefly with the treatment of various types
of dermatitis (or eczema) with Vitamin Be, including
studies of the urinary excretions of this Vitamin.

10:00 Discussion

10:20 “Diagnosis and Treatment of Vesicular and
Vesiculo-pustular Eruptions of the Hands
and Feet”

S. William Becker, M.D., Chicago

B.S., 1918, M.D., 1921,
University of Michigan;
MS., 1928, University of
Minnesota; Assistant Profes-
sor Dermatology, University
of Chicago, 1927-30, Associate
Professor since 1930. Mem-
ber A.M.A. and component
societies; American Academy
of Dermatology and Syphil-
olgy; American Dermatolog-
ical Association; and other
organisations; Diplomate of
American Board of Derma-
tology and Syphilology. Au-
thor: “Commoner Diseases of
the Skin,” 1935; “Ten Mil-
lion Americans Have It,”
1937; “Modern Dermatology
and Syphilology,” 1940 (with

S. William Becker Obermayer).

Critical study has shown that vesicular fungous
infection of the hands is almost unknown. Vesicular
eruptions of the feet (athletes’ foot) have been proven
to be caused by fungi in only five to IS per cent of
children and only 30 per cent of adults. The heat
of summer increases the percentage of fungous in-
fection to 50.

Epidermal hypersensitiveness to fungous allergens
may result in vesicular lesions on the hands
(trichophs^tids), produced by allergens reaching the
palms from the feet through the blood stream. Other
vesicular and vesiculo-pustular eruptions of the hands
(bacterids, dyshidrosis on fungous basis) cannot be
proven to be allergic, since epidermal hypersensitive-
ness does not exist in patients with such disorders.

10:50 Discussion

11:10 “Five-Day Treatment of Early Syphilis”

Loren W. Shaffer, M.D., Detroit

11:40 Discussion

12:00 Election of Ofl&cers

P. M.

12:30 Luncheon at Pantlind Hotel

MSMS

YOU ARE CORDIALLY INVITED
TO VISIT THE

MICHIGAN STATE MEDICAL SOCIETY
— HOSPITAUTY BOOTH —

Exhibit Hall, Civic Auditorium

A Southern Verandah of
Warm Friendship
and

Good Fellowship

; ' STOP AND CHA*T WITH YOUR

STATE SOCIETY OFFICERS

SECTION ON RADIOLOGY, PATHOLOGY AND
ANESTHESIA

Chairman : Frank W. Hartman, M.D., Detroit
Secretaries : Clyde K. Hasley, M.D., Detroit,
Frank J. Murphy, M.D., Detroit

Red Room — Civic Auditorium

PANEL DISCUSSION ON “SOME PHASES OF
THE CANCER PROBLEM”

9:30 A. M.

1. Diagnosis

(a) General

Henry J. VandenBerg, M.D., Grand Rapids
N. M. Allen, M.D., Detroit

(b) X-Ray

Bernard H. Nichols, M.D., Cleveland

M.D., Starling Medical
College, 1940; Practiced gen-
eral medicine and roentgen-
ology at Ravenna, Ohio,
from 1904 to 1917; com-
missioned in Medical Corps
of the U. S. Army and be-
ca7ne mstructor of Roentgen-
ology at Cornell University,
New York City. Member
Base Hospital 55 as Chief
of Department of Roentgen-
ology in September 1918, di-
rected Department of Roent-
genology in France until
end of war. Returned to
U. S. A. and became Direc-
tor of Roentgenology in the
Bernard H. Nichols Embarkation Hospital, No. 3,
New York City. Discharged
from Army, September, 1920; Director of Department
of Roentgenology in Cleveland Clinic from 1920 to
date. President Radiological Society of North Amer-
ica in 1940. Co-author with Dr. William E. Lower
of text book “Roentgenographic Studies of the

Urinary System ” has published about 100 scientific
articles.

Lawrence Reynolds, M.D., Detroit

(c) Pathology

Carl V. Weller, M.D., Ann Arbor
Donald C. Beaver, M.D., Detroit

2. Ti’eatment

(a) Surgical

Roy D. McClure, M.D., Detroit
Fred A. Coller, M.D., Ann Arbor

(b) Irradiation

Rollin H. Stevens, M.D., Detroit
IsADORE Lampe, M.D., Ann Arbor

3. Registration and Follow-Up

Shields Warren, M.D., Boston
(Biography on page 728)

Registration of cancer cases provides surest mecins
of determining morbidity rate. However, objections
by patients may vitiate accuracy. Registration at some
central point of data and specimens from rare cases
rovide best means of advancing knowledge as shown
y registry of bone sarcoma and other registries.

Fred J. Hodges, M.D., Ann Arbor
Tr.\ian Leucutia, M.D., Detroit
A. B. McGraw, M.D., Detroit

Election of Officers

_M S M S

You gain two Postgraduate Credits by attending
the Scientific Assembly at the Michigan State Medi-
cal Society Convention.

Come, and bring two or three other doctors in
your car.

732

Jour. M.S.M.S.

THE SEVENTY-SIXTH ANNUAL MEETING

I i

I i FRIDAY AFTERNOON
I September 19, 1941

! Seventh General Assembly

Black and Silver Ballroom — Civic Auditorium

j Henry R. Carstens, M.D., Presiding

ij L. Fernald Foster, M.D., and Leon De Vel, M.D.,

I Secretaries

i, P. M.

j; 1:30 “Focal Infection in the Nose and Throat —
I Retrospect and Forecast’’

D. E. Staunton Wishart, M.D., Toronto, Ontario

B.A., 1909, M. D., Uni-
versity of Toronto, 1915.

Three year's’ service in the
field with the 10th (Irish)
Division. Mediterranean Ex-
peditionary Force — Sulva
Bay, Serbia, Struma Valley
and Palestine. Surgeon-in-
Chief, Department of Oto-
laryngology, Hospital for
Sick Children, Toronto, and
Senior Demonstrator, Depart-
ment of Otolaryngology , Uni-
versity of Toronto. Author
of: Section on Surgery of

the Ear, Lewis’ System of
Surgery: Relation of Infec-
tion of the Ear and Infec-
tion of the Intestinal Tract
in Infants, Re.vults of Five
Years’ Study — Routine Hearing Tests, a?id many other
scientific articles.

Focal infection is a concept firmly established in
the minds of profession and public alike.

It is now a name which means something to every
member of the community.

Bound as the original concept was, it was enlarged
to cover too much. The_ result has been disappoint-
ment, disillusionment, misgivings, disbelief.

The pendulum is now swinging the other way.
Focal infection should give place to point of entry of
infection. Although many tonsils are better out — ;
many do not require removal. Sinuses are rarely foci
of infection.

The modern concept has always been that of the
best otolaryngologist.

Since the turn of the century there has been
marked progress in the treatment of many of the
commonly seen skin diseases. Unsightly vascular nevi
with the exception of port-wine marks can be suc-
cessfully treated in one of several ways. The acne
of adolescence, at our time considered a necessary
evil to be suffered in silence until cured by nature,
is in most instances amenable to modern therapy with
a resultant lessening in badly scarred faces. The
fungus infections which may attack any part of the
human integumnet and its appendages can in most
cases be conquered. In the treatment of those skin
infections due to cocci, new drugs administered both
internally and externally have improved therapeutic
results. Psoriasis still remains a disease of unknown
etiology and must still be considered incurable, but
there is evidence of some progress as regards its
therapy. Skin cancer, unless woefully neglected, may
be regarded as curable with present day methods of
treatment. The situation with regard to the “cur-
ability” of skin diseases has changed since the day
25 or 30 years ago that a dermatologist gave as one
of his reasons _ for selecting this specialty that “pa-
tients with skin diseases never get well.” These
newer therapeutic procedures in the above named
dermatoses will be discussed.

2 : 30 INTERMISSION TO VIEW THE EXHIBITS

3:00 “Child Health in National Defense’’

Borden S. Veeder, M.D., St. Louis, Missouri

M.D.,_ University of Pennsylvania, 1907, Professor
of Clinical Pediatrics, Washington University, School
of Medicine since 1917. Member of American Pe-
diatric Society, American Academy of Pediatrics and
other medical organizations. President of American
Board of Pediatrics. Editor, Journal of Pediatrics.
Member II, III, IV White House Conferences on
Child Health and Welfare.

A discussion of the problems of the child as re-
lated to National Defense. The situation in Germany
and Great Britain before the war and the problems
in the latter since the war started. The plans and
what is now being done in the United States as re-
gards nutrition, industrial centers and evacuation.

ACKNOWLEDGMENT: The Children’s Fund of

Michigan is sincerely thanked for its sponsor-
ship of this lecture.

3:30 “The Relationship of the Reticulo-En-
dothelial System to Cellular and Humoral
Immunity’’

D. E. S. Wishart

2:00 “New Therapy of Common Skin Diseases’’
Carroll S. Wright, M.D., Philadelphia

B.S., University of Michi-
gan, 1917; M.D., University
of Michigan, 1919. Instruc-
tor in Dermatology and
Syphilology University of
Michigan Medical School,
1920-1922; Associate Profes
sor of Dermatology and
Syphilology Graduate School
of Medicine, University of
Pennsylvania. Professor of
Dermatology.' and Syphilology
Temple University School of
Medicine. Consultant Der-
matologist to Philadelphia
Municipal Hospital; Widener
School for Crippled Chil-
dren; Shriner’s Hospital;

Carroll S. Wright Pennsylvania Institute for
Blind; Pennsylvania Institute
for the Dumb; Vineland Training School. Trustee
of Research Institute of Cutaneous Medicine. As-
sociate Editor of the “Medical World’’ and “The
^ , Weekly Roster and Medical Digest.’’ Member of
^American Dermatological Association, Society for In-
vestigative Dermatology, American Academy^ of Der-
, matology, Philadelphia College of Physicians, Nu
Sigma Nu and Sigma JCi. Author of textbooks
“Treatment of Syphilis” with Dr. Jay F. Schamberg
and “Manual of Dermatology” and numerous con-
tributions to dermatological literature.

September, 1941

C. A. Doan, M.D., Columbus, Ohio

B.S., Hiram College; M.D.,
1923 Johns Hopkins Medical
School. R.H.O., Johns Hop-
kins Hospital, 1923; Assist-
ant Department of Anatomy,
Johns Hopkins, 1924; Assist-
ant Department of Medicine
Harvard Medical School; As-
sistant Physician, Boston City
Hospital; Assistant Thorn-
dike Memorial Laboratory ;
Associate in Medical Re-
search, Rockefeller Institute,
1925-30. Fellow and mem-
ber of numerous scientific
and medical organisations.
President Ohio Public Health
Association, 1939 to ^ date;
Director-at-large N a t i o n a I
Tuberculosis Association.
Author of more than 100 scientific articles and books
on medical subjects, particularly hematology and
tuberculosis.

The phagocytic cells which comprise the Reticulo-
Endothelial System of the body have long been known
to function physiologically as conservators of essential
materials from worn out or senile blood cells. More
recently, excessive pathologic sequestration of red
cells, granulocytes or blood platelets in the par-
enchyma of the spleen, with symptom-producing d^
struction of these essential elements by hyperplastic
splenic macrophages, has resulted in recognition of
several clinical syndromes, each one of which has

733

THE SEVENTY-SIXTH ANNUAL MEETING

been effectively controlled by successful splenectomy.

Still more recently studies with “marked” dye
antigens have definitely established these phagocytic
elements as the most probable source of circulating
specific anti-bodies. This latter evidence places on
a sounder basis, the approach to the problems of
humoral immunity, and demonstrates the extremely
close association with cellular immunity.

4:00 “The Ulcer Problem and The Surgeon”

Owen H. Wangensteen, AI.D., Minneapolis

A.B., University of Min-
nesota, 1919; M.D., 1922;
Ph.D., (Surgery), 1925; Pro-
fessor in Surgery since 1931,
Director of Department and
Surgeon-i-n-Chief since 1930.
Served in World War as a
private in Student Training
Corps. Member of many
scientific and medical organ-
isations.

The importance of acid in
the genesis of ulcer will be
emphasized. Experiments per-
formed in the Surgical Lab-
oratory, in which ulcer has
been produced in a variety
of animals by stimulating the
endogenous gastric secretory
mechanism, will be reviewed.
The choice of operative procedure in the surgical
management of ulcer, which will insure effective de-
pression of the gastric secretory mechanism, will be
discussed, and the criteria of an acceptable operation
defined. Technical and nutritional problems which
confront the surgeon, affording his patient maximal
assurances of safety, will be presented.

4:30 End of Seventh General Assembly
END OF CONVENTION

O. H. Wangensteen

worth while laboratory exam-
inations; including —

Tissue Diagnosis

The Wassermann and Kahn Tests

Blood Chemistry

Bacteriology and Clinical Pathology

Basal Metabolism

Aschheim-Zondek Pregnancy Test

Intravenous Therapy with rest rooms for
Patients.

Electrocardiograms

Central Laboratory

Oliver W. Lohr, M.D., Director

537 Millard St.

Saginaw

Phone, Dial 2-3893

The pathologist in direction is recognized
by the Council on Medical Education
and Hospitals of the A. M. A.

TECHNICAL EXHIBITS

Abbott Laboratories
North Chicago, Illinois

Booth No. C-3

You are heartily invited to discuss the newer spe-
cialties with the Abbott-trained Professional Repre-
sentatives in attendance. The wide assortment of
products displayed in this exhibit merit your atten-
tion and study. Your questions are solicited. De-
scription of the items shown is prohibited by space,
so! COME IN AND SEE US!

The Baker Laboratories
Cleveland, Ohio

Booth No. D-7

Baker’s complete line of infant foods, indicating the
newer trends in modern infant feeding, will be on
display. Baker MODIFIED MILK, powder and liquid,
is a completely modified milk in which the composi-
tion of the essential food elements has been so
altered and adjusted as to closely approximate
breast milk. MELCOSE, a completely prepared liquid (
milk is very economical. MELODEX, maltose and
dextrin, is made especially for modifying fresh or
evaporated milk.

Bard-Parker Company
Danbury, Connecticut

Barry Allergy Laboratory, Inc.
Detroit, Michigan

Rudolph Beaver, Inc.
Waltham, Massachusetts

Becton, Dickinson & Co.
Rutherford, New Jersey

Booth No. C-16

Bilhuber-Rnoll Corporation
Orange, New Jersey

Booth No. C-2

The following products will be exhibited at the
Bard-Parker Booth: rib-back surgical blades, long ’
knife handles for deep surgery, renewable edge
scissors, formaldehyde germicide, and instrument
containers for the rustproof disinfection of surgical
instruments, transfer forceps for the aseptic trans-
portation of instruments, hematological case for
obtaining bedside blood samples, ortholator for ob-
taining accurate dental radiographs.

Booth No. B-15

A duplicate of the exhibit shown at the A.M.A. in
Cleveland will be brought to the Michigan State
Meeting in Grand Rapids. Services and products as
well as many research problems will be presented
in an interesting and unique manner. Both Mr.
Charles Fowler and Mr. Barry, President, will be
present to welcome all visitors.

Booth No. E-13

Newly developed all-bellied DeBakey
blades, which, held in any position,
always present a rounded cutting
edge. Also the recently developed
bent Ljungberg blades for deep and

special sur-

■ gery, such as

cholecystec-
tomy, hysterectomy, hip, spine, cleft
palate, semilunar caLrtilage. There
are also the conventional shape
blades. All blades fit every handle.

A full line of B-D Products including clinical ther-
mometers, hypodermic syringes and needles, Ace
bandages, Asepto syringes and a full line of their
diagnostic instruments including the new line of
low priced blood pressure instruments, will be on
display. Doctors will be particularly irlterested in
No. 5018 which comprises a portable type manometer
and triple change stethoscope in handy leather
pouch with slide fastener.

Booth No. B-11

Your visits are welcomed. Mr.
Laurel Johnson will be glad to
give careful attention to ques-
tions and discussions on Dilau-
did, Metrazol, Phyllicin, Theocal-
cin, etc. Register for a copy of
the new "Note Book of Original
Medicinal Chemicals.” Colored
charts — muscular, skeletal, circu-
latory, and nervous systems may
be had upon request.

Jour. M.S.M.S.

734

TECHNICAL EXHIBITS

Ernst Bischoff Company Booth No. E-19

Ivoryton, Connecticut

ACTIVIN, the first American produced shockless
foreign protein for nonspecific therapy. ANAYODIN
is an effective, non-toxic amebicide. It attacks the
amebas which have penetrated the tissues. DIA-
TUSSIN, the original drop-dose cough remedy with
a thirty-five year record of efficacy. LOBELIN-
Bischoff, a direct stimulant to the respiratory cen-
ter. The resuscitant indicated in all forms of re-
spiratory failure or depression. STYPTYSATE, a
vegetable hemostatic, with extremely high vitamin
K activity, indicated for the control of all seeping
hemorrhages.

The Borden Company Booth No. F-1

Visit the Borden exhibit to see
infant foods of unsurpassed qual-
ity. Biolac, the distinctive new
liquid infant food, affords con-
venience, economy, and optimal
nutrition. Beta Lactos is na-
ture’s carbohydrate in an im-
proved, readily soluble form.
Dryco provides formula flexibil-
ity for every feeding problem.
Also Klim, Merrell-Soule prod-
ucts, and Irradiated Evaporated
Milk. Mr. H. H. Baker and Mr.
A. D. Farrell will be in charge
of the exhibit.

Burroughs Wellcome & Co. (USA) Inc.

New York City Booths No. B-4 and B-5

A representative group of fine chemicals and phar-
maceutical preparations, together with new and im-
portant therapeutic agents of special interest to the
medical profession, will be presented.

New York City

Cameron Surgical Specialty Company Booth No. B-8
Chicago, Illinois

See the new Cameron-Schindler Flexible Gastro-
scope, the Color-Flash Clinical Camera, the Pro-
jectoray, the Mirrorlite and latest developments in
electrically lighted diagnostic and operating instru-
ments for all parts of the body. You will also be
interested in our radio frequency knives and coagu-
lators.

S. H. Camp and Company Booth No. C-18

Jackson, Michigan

A life sized reproduction of the Camp Transparent
Woman will be displayed as the central theme of a
typical service department equipped to serve pa-
tients with the various supports prescribed by phy-
sicians. A complete line of merchandise for pre-
natal, postnatal orthopedic, visceroptosis, sacro-iliac,
hernia and other specific conditions will be shown.
Experts from the Camp staff will be in attendance
to answer questions.

Ciba Pharmaceutical Products Booth No. D-6

Summit, New Jersey

Physicians are cordially invited to visit the Ciba
Booth where they will find the well known line of
CIBA specialties on display.

Mr. Frank H. Pratt will be at the booth and will be
glad to discuss these products and supply interest-
ing new information regarding many of them.

Coca-Cola Company Booth No. A- 7

Atlanta, Georgia

Coca-Cola will be served to the phy.^icians with the
compliments of the Coca-Cola Company.

Cottrell-Clarke, Inc. Booth No. D-17

Detroit, Michigan

Mostly in the east, are some half dozen specializing
printers engaged in supplying medical men with
records and stationery; still nowhere is there an
organization to compare with the personal attain-
ments of Michigan’s own COTTRELL-CLARKE, INC.
(locally and popularly known as “the physicians’
stationery folks”) in developing varied types and
sizes of folders and other ideas, all designed for
facilitating neater and better record keeping. By
all means see Cottrell-Clarke’s exhibit this year.

The Cream of Wheat Corporation Booth No. D-16
Minneapolis, Minnesota

The 5-minute “CREAM OF WHEAT” will be on ex-
hibit. This improved cereal is completely cooked in
5 minutes and has been fortified with additional
vitamin Bi (wheat germ and thiamin), iron, cal-
cium, and phosphorus.

September, 1941

Cutter Laboratories Booth No. E-4

Chicago, Illinois

Cutter Laboratories will display their latest trans-
fusion equipment, including the Saftivalve Trans-
fusion Outfit and prepared human serum and plas-
ma.

' This One Thing We Do ”

tures^

Davis & Geek, Inc. Booth No. A-4%

Brooklyn, New York

Davis & Geek, Inc. will
display its complete
line of sterile sutures
including . . . fine

gauge (0000 and 00000)
catgut ... a compre-
hensive group of su-
tures armed with swaged-on atraumatic needles
and designed for specific surgical procedures . . .
Dermalon skin and tension sutures (processed from
nylon) which, because of marked physical advan-
tages and economy, are rapidly replacing silkworm
gut and other nonabsorbable materials.

A further feature of this exhibit will be a motion
picture theater in which a diversified program of
surgical films, in full color, will be’ presented daily.

R. B. Davds Sales Company Booth No. E-21

Hoboken, New Jersey

You are invited to enjoy a drink of de-
licious Cocomalt at Booth No. E-21.
Cocamalt is refreshing, nourishing and
of the highest quality. It is fortified
with vitamins A, Bi and D; calcium
and phosphorus to aid in the develop-
ment of strong bones and sound teeth;
iron for blood; protein for strength
and muscle; carbohydrate for energy.

DePny Manufacturing Company Booth No. E-16

Warsaw, Indiana

You are invited to visit our exhibit where many
new fracture appliances and bone instruments will
be on display. Mr. Charles F. Klingel will be in
charge and will be glad to answer any of your
questions.

Detroit Creamery Company Booth No. F-3

Detroit, Michigan

Sealtest stands for quality milk, cream and ice
cream. The red and white tradename is an assur-
ance to the consumer of pure, wholesome dairy
products produced in modern, sanitary plants op-
erating under strict laboratory control.

Detroit X-Ray Sales Co. Booth No. A-4

Detroit, Michigan

The Detroit X-Ray Sales Company again takes
pleasure in presenting important advances in shock-
proof x-ray equipment, designed in the “Mattern
manner.”

We feel that a visit to our booth will interest those
contemplating the purchase of x-ray equipment.
A cordial welcome is extended. Messrs. Hanks,
McAlpine and Robinson, also Mr. R. J. Carseth, the
Mattern factory representative, will be in attend-
ance.

Dictaphone Corporation Booth No. B-13

Detroit, Michigan

You are cordially invited
to inspect the new Dicta-
phone Tnodels and to learn
how this modern dictating
machine is serving physi-
cians throughout the coun-
try. Make the Dictaphone
Booth your headquarters.
The Dictaphone displays
will be in charge of H. E.
Trapp, Grand Rapids Man-
ager, assisted by members
of his staff.

The Dietene Company Booth No. B-7

Minneapolis, Minnesota

The Dietene Company cordially invites all members
of the Michigan State Medical Society and their
guests to visit our booth.

Our representatives will be looking forward to the
opportunity of presenting our group of special pur-
pose foods.

73S

TECHNICAL EXHIBITS

Doho Chemical Corporation Booth No. E-8

New York City

The Auralgan Exhibit consists of a model of the
human auricle four feet high together with a series
of twenty-four three dimensional ear drums, mod-
eled under the supervision of outstanding otologists.
Each of these drums depicts a different pathologic
condition based upon actual case observation and
prepared, in so far as possible, with strict scientific
accuracy so as to be highly instructive and inter-
esting to all physicians.

Duke Laboratories, Inc. Booth No. C-4

Stamford, Connecticut

The Duke Laboratories, Inc., will demonstrate the
original, American-made, stretchable, adhesive sur-
faced bandage, Elastoplast, which is used whenever
compression and support are required. Samples of
Mediplast and Elastoplast Occlusive dressing, now
being so widely used in plants on Defense work,
will be available. Ask for samples of the prescrib-
er’s cosmetics — Nivea and Basis Soap — too.

The Ediphone Company Booth No. E-5

Grand Rapids, Michigan

THE E D I-
PHONE COM-
PANY extends
a cordial invi-
tation to all
physicians to
visit the dis-
play of EDI-
PHONE equip-
ment. See the
new Miracle
Model Edison
Voice Writ-
er, also new
Streamline
Cabinet de-
signs, manu-
factured by
Edison, who invented and perfected sound record-
ing. We welcome opportunity to demonstrate and
discuss its application in the medical profession.

J. H. Emerson Company Booth No. D-18

Cambridge, Massachusetts

J. H. Emerson Company will demonstrate the new
Emerson Combination Resuscitator, Inhalator, Aspira-
tor apparatus, a safe, self-adjusting automatic breath-
ing machine. A new, simplified mechanical principle
has been incorporated in this unit which will be of
interest to the doctor. The Emerson Diaphragm Type
Respirator and the Emerson Suction pressure Boot for
peripheral vascular diseases will also be on display.

H. G. Fischer & Co. Booth No. B-16

Chicago, Illinois

To every visitor at the Michigan State Medical So-
ciety we give this special invitation: Look under

the hood of the new FISCHER models of apparatus
shown! FISCHER shockproof x-ray apparatus, short
wave units, ultra-violet and other generators are
built to stand the very hardest day-by-day usage.
Demand to be shown the real under-the-hood facts
about FISCHER Models.

C. B. Fleet Company Booth No. E-14

Lynchburg, Virginia

Gerber Products Company Booth No. E-12

Fremont, Michigan

The complete
line of Ger-
b e r Baby
Foods will be
on display.
There are two
precooked
dry cereals,
one a wheat,
the other an
oatmeal cere-
al. Of the
canned foods,
there are both strained and Junior or chopped foods.
Booklets available for distribution to mothers or
patients on special diets as well as professional lit-
erature will be sent to registrants, for examination.

Hack Shoe Company Booth No. A-2

Detroit, Michigan

Twenty-five years of evolution in health shoe con-
struction will be exemplified in the Hack Shoe Com-
pany exhibit.

This pioneer prescription shoe organization will also
display a series of roentgenographs demonstrating
how the foot bones lie in correctly and incorrectly
fitting shoes.

HACK-O-PEDIC clubfoot and surgical shoes and
TRI-BANLANCE shoes for men, women and chil-
dren complete the exhibit.

Gerber's

Strained

Oatmeal

Hanovia Chemical & Mfg. Company Booth No. C-17
Newark, New Jersey

The very latest in ultra-violet equipment will be
demonstrated, including the outstanding uses of
ultra-violet radiation in the fields of science, medi-
cine and public health. Don’t fail to see our new
line of self-lighting ultra-violet high-pressure mer-
cury arc lamps. Short and ultra short wave appara-
tus, Sollux Radiant Heat Lamps and our latest de-
velopment, quartz ultra-violet lamps for air sanita-
tion.

J, F. Hartz Company Booths No. E-6 and E-7

Detroit, Michigan

All physicians are invited to visit the booth of the
J. F. Hartz Company — the progressive medical sup-
ply firm of Detroit who are nationally known.

An interesting display of instruments, equipment,
and pharmaceuticals may be seen.

This firm has recently added another fioor to care
for the expanding business of its manufactured
pharmaceuticals which are made under strict labora-
tory control, and in compliance with the regulations
of the Federal Food and Drug Department.

H. J. Heinz Company Booth No. E-18

Pittsburgh, Pennsylvania

The makers of Heinz Strained and Junior Foods ap-
preciate the confidence which the members of the
Michigan State Medical Society have expressed in
their recommendation of these foods for infant feed-
ing and special diets. F. B. Heard and H. A. Elen-
baas are at your service and will welcome members
and friends at the exhibit.

Holland-Rantos Company, Inc. Booth No. F-11

New York City

The latest developments in the field of medically
prescribed contraceptives will be featured at the
booth of the Holland-Rantos Company. Rantex
masks and Rantex caps for operating room will be
of unusual interest to surgeons who are looking
for something comfortable yet efiicient in this line.

Phosphe-Soda (Fleet) is a highly concentrated and
purified, aqueous solution of sodium phosphates. It
is nontoxic, rapid but mild in action without irri-
tation of the gastric or intestinal mucosa. It is
indicated for hepatic dysfunction and for its tho-
rough eliminating and cleansing action on the upper
and lower gut.

General Eleetric X-Ray Corp. Booth No. A-5

Detroit, Miehigan

The G. A. Ingram Co. Booths No. D-21 and D-22

Detroit, Miehigan

The G. A. Ingram Company extends an invitation
to all visitors at the Michigan State Medical Con-
vention to make their booth their headquarters and,
especially, to investigate their new line of diagnos-
tic instruments and their complete line of genuine
Swedish stainless steel instruments. They will also
show the latest in electrical equipment.

We cordially invite the physicians and their fam-
ilies who attend this meeting to make use of the
lounge facilities provided at our booth for their
comfort. We particularly look forward to a visit
from users of our equipment and a cordial invitation
is extended to all physicians who may have tech-
nical problems to discuss with our staff in attend-
ance.

Jones Metabolism Equipment Company Booth No. D-5
Chicago, Illinois

Interview our representative, William Niedelson,
about the development of the first waterless, basal
through 20 years by the addition of many scientific
devices to assure accuracy, operative simplicity and
guarantee the purchaser a lifetime of use without
repair expense.

736

Jour. M.S.M.S.

TECHNICAL EXHIBITS

“The ‘Junket’ Folks” Booth No. B-3

Chr. Hansen’s Laboratory
Little Falls, New York

■‘THE ‘JUNKET’ FOLKS” will serve rennet-custards
made with either “Junket” Rennet Powder or “Jun-
ket” Rennet Tablets. There is also a display of
“Junket” Brand Food Products. Enlarged photo-
graphs show how the rennet enzyme in rennet-
custards transforms milk into softer, finer curds.
Rennet-custards are widely recommended for in-
fants, children, convalescents, postoperative cases
and as a delicious, healthful dessert for the whole
family. Fully informed attendants on duty.

Kalak Water Company Booth No. E-17

New York City

Visit the KALAIi WATER booth and ask the rep-
resentative how KALAK WATER may be employed
to minimize the discomforts that so frequently fol-
low the administration of the Sulfonamides. Ask
the representative to serve you with a glass of
KALAK WATER and learn for yourself how deli-
cious and refreshing KALAK WATER really is
when it is properly served.

mans’ “Nutritional Deficiencies.” Leaman’s “Man-
agement of the Cardiac Patient,” today’s sales lead-
er, will be displayed, as will Thorek’s three-volume
“Modern Surgical Technic.”

The McKesson Appliance Company Booth No. D-20
Toledo, Ohio

The McKesson Appliance Co. will exhibit a complete
line of scientific equipment involving the uses of
anesthetic gases and oxygen therapy. Both water-
less and water spirometer type basal metabolism
units will be shown. Practical demonstrations will
be made on the new direct reading electrocardio-
graph.

M & It Dietetic Laboratories, Inc. Booth No. C-11
Columbus, Ohio

Similac, a completely modified milk especially pre-
pared for infants deprived either partially or en-
tirely of breast milk, will be featured. Mr. David
O. Cox and Mr. L. A. MacDonald will appreciate the
opportunity to discuss the merits of Similac and its
suggested application for both the normal and
special feeding cases.

A. Kuhlman & Company Booth No. A-8

Detroit, Michigan

The Kuhlman display will consist of a selected line
of diagnostic instruments, a special line of indwelling
catheters, cystoscopes, urologic instruments, pneumo-
thorax apparatus, and a general line of instruments
and accessories for physicians and surgeons.

Lea A Febiger Booth No. D-14

Philadelphia, Pennsylvania

Lea & Febiger will exhibit Portis’ Digestive Dis-
eases, Kraines’ Psychoses, Ballenger’s Manual,
Rowe’s Elimination Diets, Lewin’s The Foot and
Ankle, Rony’s Obesity and Leanness and new edi-
tions of Holmes and Ruggles’ Roentgenology. Jos-
lin’s Diabetes and Manual, Comroe’s Arthritis,
Bridges’ Dietetics, Spaeth’s Ophthalmology and
Kessler’s Accidental Injuries.

Lederle Laboratories Booth No. E-22

New York City

You are cordially invited to visit the Lederle Ex-
hibit which will feature colored slides on the re-
fining of Antitoxins. These slides were taken from
a new motion picture film on this subject.

They will exhibit the many specialties for which
they are noted and the latest releases in Sulfona-
mide drugs. Literature on the various Sulfonamides
will be available.

Libby, McNeill & Libby Booth No. B-17

Chicago, Illinois

You are cordially invited to visit Libby, McNeill &
Libby’s exhibit where attendants will point out the
merits of Homogenized Baby Foods, Chopped Foods
and Evaporated Milk. Libby’s special fpthod of
Homogenization makes Libby’s Baby Foods extra
smooth, extra easy to digest.

Liebel-Flarsheim Company Booth No. C-7

Cincinnati, Ohio

Liebel-Flarsheim Company will ex-
_ . hibit the well-known L-F Short
'■ Wave G-enerators as well as the

] I famous Bovie Electro-Surgical Units
, Ih Br l_J and other new and interesting elec-
tro-medical apparatus.

, A cordial invitation is extended to
visit The Liebel-Flarsheim booth to inspect this
outstanding equipment and have it demonstrated to
you.

Eli Lilly and Company Booth No. C-1

Indianapolis, Indiana

Eli Lilly and Company will demonstrate the germi-
cidal efficacy of “Merthiolate” (Sodium Ethyl Mer-
curi Thiosalicylate. Lilly) and the compatibility of
the antiseptic with body cells and fluids. Other
new and useful products will be featured.

J. B. Lippincott Company Booth No. E-11

Philadelphia, Pennsylvania

New Lippincott books of interest to every physician
are Grollman’s “Essentials of Endocrinology,” To-
bias’ “Essentials of Dermatology,” Haden and
Thomas “Allergy in Clinical Practice" and You-

Mead Johnson & Company Booths No. C-21 and C-22
Evansville, Indiana

“Servamus Fidem” means We Are Keeping the
Faith. Almost every physician thinks of Mead
Johnson & Company as the maker of Dextri-Mal-
tose, Pablum, Oleum Percomorphum and other in-
fant diet materials. But not all physicians are
aware of the many helpful services this progressive
company offers physicians. A visit to Booths C-21
and C-22 will be time well spent.

Medical Arts Surgical Supply Company

Grand Rapids, Michigan Booths No. C-5, C-6 and B-14

The Medical Arts Surgical Supply Company of the
best city will show the exclusive line of Liebel Flar-
sheim short wave generators, the latest items in
the beautiful Ritter ear, nose and throat equipment,
and a complete suite of the Hamilton Nu Tone furni-
ture along with the latest in autoclave and steril-
ized units. An invitation is extended to all doctors
to call at these booths.

Medical Case History Bureau Booth No. D-9

New York City

Simplifying the Doctor’s History Record and Book-
keeping System with the INFO-DEX RECORD CON-
TROL SYSTEM.

Maintenance of accurate, informative data on both
history and financial records is essential in the
modern doctor’s practice. The INFO-DEX Record
Control System helps to keep a constant finger
on the physical and financial pulse of the patient.
’This system correlates information almost auto-
matically for instant reference and research work.
Its method of cross-indexing interesting cases ac-
cording to the disease is unique and exclusive.

The Medical Protective Company Booth No. D-8

Fort Wayne, Indiana

The Medical Protective Company invites you to visit
its booth. Medical Protective Service is an institu-
tion of the Medical profession whose legal liability
problems we have concentrated upon for 42 years.
Bring your professional liability questions and
problems to us.

The Mennen Company Booth No. A-1

Newark, New Jersey

’The Mennen Company will exhibit
their two baby products — ^Antiseptic
Oil and Antiseptic Borated Powder.
The Antiseptic Oil is now being
used routinely by more than 90 per
cent of the hospitals that are im-
portant in maternity work. Be sure
to register at the Mennen exhibit
and receive your kit containing
demonstration sizes of their shav-
ing and after-shave products.

Melliu’s Food Company Booth No. E-15

Boston, Massachusetts

Physicians are cordially invited to call and to place
before our repesentatives all questions regarding

September, 1941

TECHNICAL EXHIBITS

the composition of Mellin’s Food and its usefulness
in infant and adult feeding-. It is suggested that
constipation in infancy and the preparation of nour-
ishment for adult patients who are far below nor-
mal as a result of prolonged illness or faulty diet
are particularly interesting topics for discussion.

The Wni. S. Merrell Company Booth No. B-2

Cincinnati Ohio

The Merrell exhibit will feature Oravax, the oral ca-
tarrhal vaccine in enteric coated tablets for protec-
tion against the common cold; as well as other new
prescription specialties of timely interest. Merrell
representatives will be at the booth ready to show
these products and answer any question.

Michigan Medical Service Booth No. A-6

Michigan Hospital Service
Detroit, Michigan

Complete information about the Medical Service and
Surgical Benefit Plans of Michigan Medical Service
will be available in this featured exhibit of the
results of operation of the doctors’ prepaid group
medical service program.

There will also be an interesting display of the
working of the companion hospital service plan of
Michigan Hospital Service.

The C. V. Mosby Company Booth No. D-3

St. liOnis, Missouri

Physicians and surgeons interested in the new
developments in medicine and surgery are cordially
invited to inspect the new publications which will
be on display at the Mosby Booth. Outstanding
new volumes on surgery, dermatology, pediatrics,
gynecology, heart diseases, X-Ray, and practice of
medicine will be shown.

National Dive Stock and Meat Board Booth N^o. B-12
Chicago, Illinois

The exhibit of the National Live Stock and Meat
Board will portray Meat as a source of the essen-
tial food elements, protein, fats, carbohydrates, cal-
cium, phosphorus, iron, copper and six vitamins
with special emphasis on the factors of the vita-
min B complex.

Nestle’s Milk Products, Inc. Booth No. D-19

New York City

The Nestle’s Milk Products,
Inc., exhibit will feature Lac-
togen which has given suc-
cessful results in infant feed-
ing for more than 15 years.
Mr. J. B. Gibbs will be in
charge of the exhibit.

Parke, Davis & Company

Deroit, Michigan Booths Nos. C-12, C-13 and C-14

Featured in the Parke-Davis exhibit will be the
sex hormones, theelin and theelol; antisyphilitic
agents, such as mapharsen and Thio-Bismol; pos-
terior lobe preparations, including pitiiitrin. pitocin
and pitressin; and various adrenalin chloride prep-
arations.

Petrolagar Laboratories, Inc. Booth No. D-2

Chicago, Illinois

Petrolagar Laboratories, Inc. offer, in addition to
samples of the Five Types of Petrolagar, an inter-
esting selection of descriptive literature and an-
atomical charts. Ask the Petrolagar representa-
tives to show you the HABIT TIME booklet. It is
a welcome aid for teaching bowel regularity to your
patients.

Philip Morris & Company Booth No. E-1

New York City

Philip Morris & Company will demonstrate the '
method by which it was found that Philip Morris ,
cigarettes, in which diethylene glycol is used as the •
hygroscopic agent, are less irritating than other I
cigarettes. Their representative will be happy to }
discuss researches on this subject, and problems *
on the physiological effects of smoking. ^

Picker X-Ray Corporation Booth No. B-10

New York City

Visitors to the Picker X-Ray Corporation’s booth j
will have an opportunity of seeing the well-known i
Picker-Waite “Century.” This diagnostic unit pro- |
vides for radiography and fiuoroscopy in all positions I
from the vertical to the Trendelenburg — either hand 3
or motor operated. Also on display will be a fine ^
example of a combination portable and mobile j
shockproof x-ray unit. This apparatus is suitable ;
for general office use or portable work in the pa- {
tient’s home. A number of newly developed x-ray *
accessories and diagnostic opaque chemicals will '
be exhibited. <

Professional Management Booth No. F-2

Battle Creek, Michigan

a Bring your professional and business
problems for Free Consultation Serv-
ice with any of the Professional Man-
agement Staff. Henry C. Black and

Allison E. Skaggs, Battle Creek; Wen-
dell A. Persons, Saginaw: Willis B.

Mallory, Detroit; and Morris C. Flan-
ders, Grand Rapids, will all be avail-
able to members of the Michigan State
I Medical Society.

Randolph Surgical Supply Cumpany, Booth No. B-9
Detroit, Michigan

A varied assembly of the newest in medical and
surgical equipment will be featured at the Randolph
Surgical Supply Company exhibit. A skilled and
efficient personnel will explain if you wish any of
the features of the new equipment, diagnostic in-
struments, surgical supplies and electrical equip-
ment. You will find your visit at the Randolph dis-
play very much worth while. Representatives in at-
tendance will include Theo Ward, Harold Storm-
hafer, Arthur Rankin and Cliff Randolph.

Riedel-de Haen, Inc. Booth No. B-6

New York City

The Riedel-de Haen exhibit will feature two chem-
ically pure bile acids: Decholin, the true choleretic,

and Degalol, the fat emulsifier. Physicians are in-
vited to register for abstracts of clinical reports
on these products. Attending representatives will
appreciate the opportunity to discuss the latest
developments in the therapeutic application of
chemically pure bile acids.

Pelton & Crane Company Booth No. D-4

Detroit, Michigan

The Pelton & Crane Company will exhibit its com-
plete line of office sterilizers, autoclaves and operat-
ing lights; also, fountain cuspidors and other spe-
cialty items. The exhibit will be in charge of Mr,
C. K. Vaughan, who looks forward to the pleasure
of renewing old acquaintances.

Pet Milk Sales Corporation Booths Nos. C-9 and C-10
St. liOuis, Missouri

An actual working model of a milk
condensing plant in miniature will be
exhibited by the Pet Milk Company.
This exhibit offers an opportunity to
obtain information about the produc-
tion of Irradiated Pet Milk and its uses
in infant feeding and general dietary
practice. Miniature Pet Milk cans will
be given to each physician who visits
the Pet Milk Booth.

.S.M.A. Corporation Booth No. D-1

Chicago, Illinois

Among the technical exhibits at the convention this
year is an interesting new display, which represents
the selection of infant feeding and vitamin prod-
ucts of the S.M.A. Corporation. Physicians who
visit this exhibit may obtain complete information,
as well as samples, of S-M-A Powder and the spe-
cial milk preparations — Protein S-M-A (Acidulated),
Alerdex and Hypo-Allergic Milk.

Sandoz Chemical Works, Inc. Booth No. D-15

New York City

This exhibit will stress Council-accepted products:
Gynergen (ergotamine tartrate) for migraine and
uterine hemostatis; Digilanld, the crystallized initial
glycosides of Digitalis lanata, standardized gravi-
metrically and biologically; Scillaren and Scillaren-B,
pure cardiodiuretic squill principles, and Dandoptal,
an effective hypnotic. Also the original gluconate
preparations of calcium (Calglucon) for oral and
parenteral therapy.

738

Tour. M.S.M.S.

TECHNICAL EXHIBITS

W. B. Saunders Cnmpany Booth No. B-1

Philadelphia, Pennsylvania

Of particular interest are such new books as Ladd
& Gross’ “Abdominal Surgery in Infancy and Child-
hood,” Kilmer & Tuft’s “Clinical Immunology, Bio-
therapy and Chemotherapy,” Steinbrocker’s “Ar-
thritis,” Johnstone’s “Occupational Diseases,” Gray-
biel & White’s “Electrocardiography in Practice,”
Krusen’s “Physical Medicine,” Novak’s “Obstetrical
and Gynecological Pathology,” Walters & Snell’s
“The Gallbladder and Its Diseases,” the 1941 Mayo
Clinic Volume, Griffith & Mitchell’s “Pediatrics,” and
a number of other important new books and new
editions.

Schering Corporation Booth No. E-2

Bloomfield, New Jersey

The Sobering exhibit includes real and striking re-
cent advances such as SULAMYD, highly effective
sulfacetimide of considerably lower toxicity: orally
active sex hormones, ORETON-M, PROGYNON-DH
and PRANONE tablets; efficient BARAVIT for bulk
laxative therapy: and the new physiological antacid,
LUDOZAN tablets, forming a true protective gel in
your patient’s stomach.

^ientific Sugars Company Booth No. C-15

Columbus, Indiana

Scientific Sugars Company will display Cartose,
Hidex, and the Kinney line of nutritional products.
Physicians are cordially invited to stop. Well in-
formed representatives will be in attendance.

Sharp & Dohme Booth No. D-12

Philadelphia, Pennsylvania

Sharp & Dohme will show their new modern dis-
play this year, featuring “Delvinal” Sodium, “Lyo-
vac” Normal Human Plasma, “Lyovac” Bee Venom
Solution, and other “Lyovac” biologicals. There will
also be on display a group of new biological and
pharmaceutical specialties prepared by this house,
such as “Propadrine” Hydrochloride products, “Ra-
bellon,” “Padrophyll,” “Riona,” “Depropanex” and
“Ribothiron.” Capable well-informed representa-
tives will be on hand to welcome all visitors and
furnish information on Sharp & Dohme products.

Smith, Kline & French Laboratories Booth No. F-10
Philadelphia, Pennsylvania

This year. Smith, Kline & French Laboratories be-
gins its second century of service to the medical
profession. The members of the Michigan State
Medical Society are cordially invited to visit this
exhibit and discuss the products displayed. These
will include benzedrine inhaler, benzedrine sulfate
tablets, benzedrine solution, and pentnucleotide.

Frederick Stearns & Company ,

Detroit, Michigan Booths No. D-10 and D-11

Doctors are cordially invited to visit our attractive
convention booths, to view and discuss outstanding
contributions to medical science developed in the
Scientific Laboratories of Frederick Stearns &
Company.

Our professional representatives will be pleased
to supply all possible information on the use of
such outstanding products as Neo-Synephrin Hydro-
chloride for intranasal use, Muci^ose for bulk and
lubrication. Ferrous Gluconate, Potassium Gluconate,
Gastric Mucin, Susto, Trimax, Appella Apple Pow-
der, Nebulator with Nebulin A, and our complete
line of vitamin products, together with liver ex-
tract U.S.P., oral and subcutaneous for the treat-
ment of pernicious anemia as well as other prod-
ucts will be readily available.

E. R. Squibb & Sons Booth No. D-13

New York City

A number of new and interesting chemotherapeutic
specialties, vitamin, glandular and biological prod-
ucts will be featured in the Squibb Exhibit. Well
informed Squibb Representatives will be on hand to
welcome you and to furnish any information de-
sired on the products displayed.

U. S. Standard Products Company Booth No. C-20
Woodworth, Wisconsin

MAGSORBAL will be on display by the U. S. Stand-
ard Products Company at the State Medical Meet-
ing in Grand Rapids. Have our representative tell
you about the merits of this product. Other items
of great interest will be on display.

September. 1941

Wall Chemicals Corporation Booth No. E-3

Detroit, Miehigan

Wall Chemicals Corporation, a division of the Liquid
Carbonic Corporation, will have on display a quan-
tity of compressed gas anesthetics and resuscitants.
There will also be a complete line of oxygen ther-
apy _ equipment including the “Walco” oxygen hu-
midifier, for the nasal administration of oxygen,
and the “Walco” oxygen face mask.

Westinghouse X-Ray Co., Inc. Booth No. C-19

Detroit, Michigan

The Westinghouse X-Ray Division will display the
most recent development of compact x-ray equip-
Considering the size, there is greater power
than heretofore. The recently publicized bacteri-
cidal “Sterilamp” and “Thin Window Lamp” will be
available for examination. The “Scialytic,” standard
of surgical lighting will be shown in the latest
models.

White Laboratories, Inc. Booth No. E-9

Newar'k, New Jersey

White Laboratories, Inc., will present White’s Cod
Liver Oil Concentrate Liquid, Tablet and Capsule
(and White’s Thiamin Chloride Tablet) — all Council-
accepted.

The practical advantages provided by cod liver oil
concentrate as an economical and convenient meas-
ure of vitamins A and B prophylaxis and therapy
will be discussed. Pertinent information concerning
our newer knowledge of the vitamins and vitamin
deficiency states will be offered for consideration.

Wiuthrop Chemical Company, Inc. Booth No. C-8

New York City

A cordial invitation is extended to every member
of the Michigan State Medical Society to visit Booth
No. C-8 where representatives will gladly discuss
the latest preparations made available by this firm
You will receive valuable booklets dealing witli
anesthetics, analgesics, antirachitics, antispasmodics
antisyphilitics, diagnostics, diuretics, hypnotics
sedatives and vasodilators.

John Wyeth & Brother, Inc.
Philadelphia, Pennsylvania

Booth No. A-3

You are cordially invited to visit the John Wyeth
and Brother exhibit where the following pharma-
ceutical specialties will be on display
Amphojel, Wyeth’s Alumina Gel, for the control of
hyperacidity and peptic ulcer. Wyeth’s Hydrated
Alumina Tablets, for the convenient control of
hyperacidity. Kagomagma, Wyeth’s magma of
ali^ina and kaolin, for the control of diarrhea
Wyeth’s Vitamin B Complex Elixir. A-B-
M-C Ointment, the rubefacient, counter-irritant, for
the relief of arthritic pain. Bepron, Wyeth’s Beef
Liver with iron. Bewon Elixir, Wyeth’s palatable
appetite stimulant.

Zimmer Manufacturing Company Booth No. E-20

Warsaw, Indiana

A complete line of fracture equipment will be
on display. Your factory representative, Mr. Fisher
will be pleased to see you, and demonstrate any
Item. Of special interest— a sterilizable bone plate
and ^rew container which should be seen, the new
S-M-O Bcme Plates and Screws, a screw driver

Luck Bone Saw complete

with all attachments.

-MSMS-

The Glad-hand Awaits You at the
1941 MSMS Convention!

739

1

THE MICHIGAN POSTGRADUATE PROGRAM
Autumn, 1941

The Michigan State Medical Society, in cooperation with the University of
Michigan Medical School, Wayne University College of Medicine, and the Michi-
gan Department of Health, announces the semi-annual extramural course for
practising physicians to be given in October, 1941.

CENTERS DATES

Ann Arbor October 2, 9, 16, 23

Battle Creek* September 30, October 7, 14, 21

Flint October 1, 8, 15, 22

Grand Rapids October 2, 9, 16, 23

Lansing* October 2, 9, 16, 23

Mount Clemens October 1, 8, 15, 22

Saginaw* September 29, October 6, 13, 20

Traverse City* October 3, 10, 17, 24

Subjects

The Modern Treatment of Fractures.

The Recognition and Prevention of Accidents of Pregnancy. (Obstetrician).
The Complications of Pregnancy. (Internist).

Emergency Drugs in General Practice.

The Office Management of the Allergic Patient.

The Office Management of the' Diabetic.

The Diagnosis and Management of Cancer of the Gastro-intestinal Tract.
Abnormalities of Growth and Development in Children.

The Course Is Offered Without Cost to All Legally Qualified Physicians

in Michigan

Intramural Courses

Nutritional and Endocrine Problems.

November 3-6, inclusive. University Hospital, Ann Arbor.
Electrocardiographic Diagnosis.

November 3-8, inclusive. University Hospital, Ann Arbor.

Anatomy.

September 10-throughout year. (For further information write or call Dr. M. R.
Collins, Wayne University Medical School, Detroit).

Anatomy.

Second Semester (Thursdays), 1942. West Medical Building, University of
Michigan, Ann Arbor.

Details of intramural courses will be available soon.

Chairman, Committee on Postgraduate Medical Education
Michigan State Medical Society
Room 2040, University Hospital
Ann Arbor, Michigan

*Spring- programs will be given in Kalamazoo, Jackson, Bay City, and Cadillac.

740

Jour M.S.M.S.

^ THE BUSINESS SIDE OF MEDICINE ^

THE BUSINESS SIDE OF MEDICINE IN BOOM TIMES

By ALLISON E. SKAGGS and HENRY C. BLACK

Practicing medicine in boom times is now
being experienced by many doctors for the first
time in their lives. Even those men who were
practicing during the strenuous days of thfe first
World War and during the affluent years of
the late ’20’s find business situations a bit dif-
ferent today. Money is circulating rapidly; most
employables are employed ; wages have been hiked
upward; and the consequent greater demand for
medical services finds fewer doctors available
due to the numbers in military service. During
the past ten years the “times” have been blamed
for poor collections, insufficient business, low
prices ' and inability to expand office facilities
and equipment. Now that “hard times” cannot
be blamed for these situations, it would seem
at first glance that everything should be rosy,
yet^ many of the doctors who have started prac-
tice in the last ten years will make the same
mistakes that were made by their predecessors
during the first World War, and many of
those who experienced the depression which be-
gan in 1929 will allow their fears of what is
to come to confuse their judgment again in this
change of economic conditions, particularly as
to the “timing” of the economic cycle.

While most doctors who were not already
operating at full capacity are experiencing in-
creased income, it is necessary for them to realize
that taxes, particularly income taxes, will in many
cases use up the increase in net profits. Instead
of paying a nominal amount on each March 15,
it may be necessary to set aside a substantial
sum each month as a part of the regular ex-
penses so that funds will be available for the
tax when due. Serious errors leading to finan-
cial embarrassment will result from ignoring this
situation and spending or investing the money
as it comes in without thought for future tax
needs.

Although increased volume of work usually
brings increased cash receipts, it also increases
expenses, and it has been our experience that

September. 1941

the actual percentage of collections in good times
is often lower than in years of depression.
While this may seem like a paradox, we know it
to be true, probably due to the fact that during
boom years optimism prevails and patients make
the same mistakes outlined above, spending their
money and incurring obligations for houses, fur-
nishings, cars, and other things which they would
deny themselves during poor years, with the re-
sult that there are not sufficient funds to pay
normal living expenses, such as medical bills,
when they come due. Neglected collections usu-
ally result not only in a loss of money but in
a deterioration of the quality of the practice
as the dead-beat and slow-paying patients grad-
ually gravitate to the doctor whose business proce-
dures are lax.

Mistakes in judgment will be made during
the coming years in two entirely opposite but
equally unfortunate ways. The young man ex-
periencing “easy money and lots of it” for the
first time and with more practice than he
knows what to do with, will in some cases go
completely overboard in expanding his office,
taking on help, buying property, making too many
long term commitments in life-insurance and in-
vestments requiring continued regular payments,
and will find himself eventually overexpanded
in his finances just as many others did in 1929
and ’30. At the other extreme, the ultra-con-
servative, remembering the bitter lesson of the
last depression and confusing the present boom
with the industrial boom of the late ’20’s, will
miss opportunities for professional advancement,
fail to expand his practice as he should, over-
economize and end up with a practice that is
slipping, a lack of faith in things financial, and
a final realization of that unfortunate situation
— an irretrievably lost opportunity.

Both of these errors can be avoided only by ob-
jective thinking and planning based on accurate
information. All doctors know why a patient
should not diagnose his own case and experi-

741

THE BUSINESS SIDE OF MEDICINE

ment on his own treatment. Lack of coordi-
nated facts, lack of experience, and the difficulty
of objective reasoning are three of the many
reasons. In the doctor’s planning of his own
business affairs he, too, often practices “patent
medicine.” By careful records of his assets, his
debts, his income and his expenses, he can have
the facts ; by analysis and comparison of his own
years of experience, he can estimate the future,
and by doing these two things painstakingly over
a period of time, he will develop a judgment suffi-
cient for his needs. Few optimistic ideas and
few pessimistic fears are wholly accurate. As a
famous politician of this generation says, “Let’s
look at the record.”

Charles Dickens wrote — “Annual income 20
pounds, annual expenditures 19.96, result happi-
ness ; annual income 20 pounds, annual expen-
ditures 20.06, result misery.” So close is the
margin between pleasant, unworried business af-
fairs and the harassed life of a man forever be-
hind the well-known “eight ball” that we are
prompted to give an example, showing how slight
an additional cash requirement can bring an un-
balanced personal budget, particularly at this
time. Supposing you took in $10,000.00 last
year, and your office expenses were $4,000.00,
leaving you a net of $6,000.00; just suppose that
your living expenses were $5,000.00, and your
life insurance $500.00, which left you a net sur-
plus of $500.00, with an income tax to pay out
of that amounting to $175.00, which finally left
$325.00 neither spent nor invested. At the be-
ginning of this year you bought a house agree-
ing to pay $50.00 per month. That is $600.00 per
year and you must make $275.00 more than last
year in order to come out even. Then, suppos-
ing your income tax is tripled as is very likely
this year, adding $350.00 to your net deficit. It
is the long term obligation to fixed monthly pay-
ments without knowing in advance that there will
be sufficient surplus to take care of these pav-
ments, which, added to the new tax burden, will
cause the most financial embarrassment.

To avoid such errors in judgment in times
like these, there is nothing so necessary as com-
plete accurate knowledge of your income, ex-
penses, requirements for the payments of debts,
and the relation they bear to assets and liabilities.
In other words, prepare and maintain a case
history on your business affairs so that your fi-
nancial decisions are based on the same accurate

knowledge as are your professional decisions. Inj
this way, what could be a serious time for you'
can be made into an opportunity, which probably
will not repeat itself during your lifetime.

M s MS

PROPOSED AMENDMENTS TO CONSTITU- 1
TION AND BY-LAWS OF MICHIGAN STATE
MEDICAL SOCIETY ]

I

The following amendments were presented at the
1940 Convention and according to the Constitution were
referred to the 1941 SessMn of the House of Delegates
for final consideration :

Constitution

1. Amend Article IV, Section 3 to read as follows:
“The officers of this Society, Past Presidents, and
Members of The Council shall be ex-officio members of
the House of Delegates without power to vote.”

Comment : This amendment adds the past presidents
of the Michigan State Medical Society to the ex-
officio members of the House of Delegaites.

2. Amend Constitution, Article IX, Section 4, to read
as follows : “The Secretary shall collect all annual dues
and all monies owing to the Society, depositing them in
an approved depository and disbursed by him upon
order of The Council, or invested by him in United -
States Government bonds with approval of The Coun-
cil.”

Comment : The Reference Committee, in 1940,

recommended that this proposed amendment re finances
be rejected. i

3. Amend Article XII, Section 1 to read as follows:
“The House of Delegates may amend any article of
this constitution by a two-<thirds vote of the Delegates
seated at any annual session, provided that such amend-
ment shall have been presented in open meeting at the
previous annual session, and that it shall have been
published at least once during the year in the Journal
of the Society, or sent officially to each component
society at least two months before the meeting at which
final action is to be taken.”

Comment : This amendment changes the word

“present” to “seated.” See next amendment re “Sessions
and Meetings.”

4. Amend Constitution by adding a new article to be I
known as Article XII :

“SESSIONS AND MEETINGS

“Section 1. A session shall mean all meetings at any
one call.

“SeOtion 2. A meeting shall mean each separate con-
vention at any one session.” I;

Comment : This new Article is for the purpose of
clarifying what is meant by the terms “sessions and j
meetings.”

.S. Amend the Constitution bv renumbering old Arti- j
cle XII to “XIII.”

By-Laws

6. Amend By-Laws, Chapter 10, Section 1, to read
as follows : “These By-Laws may be amended by a
majority vote of the delegates present, after the pro-
posed amendment is laid on the table for one meeting.
These By-Laws become effective immediately upon adop-
tion.”

Comment: Th's amendment consists of substituting
the word “meeting’’ for the word “session” to bring
the By-Laws in conformity with the Constitution upon
the adoption of above proposed amendments, thereto.

Jour. M.S.M.S.

742

WEHENKEL SANATORIUM

A MODERN, comfortable sanatorium adequately equipped for all types of medical and
surgical treatment of tuberculosis. Sanatorium easily reached by way of Michigan

Highway Number 53 to Corner of Gates St., Romeo, Michigan.

For Detailed Information Regarding Rates and Admission Apply

DR. A. M. WEHENKELt Medical Director, City Offices, Madison 3312*3

INTERNATIONAL MEDICAL ASSEMBLY

Inter-State Postgraduate Medical Association of North America

Public Auditorium, Minneapolis, Minnesota, October 13, 14, 15, 16, 17, 1941

Pre-Assembly Clinics, October 11; Post-Assembly Clinics, October 18, Minneapolis Hospitals
President, Dr. Roscoe R. Graham Director of Exhibits, Dr. Arthur G. Sullivan

President-Elect, Dr. George R. Minot Treasurer _and Director of Foundation Fund,

Dr. Henry G. Langworthy

Chairman, Program Committee, Dr. George W. Crile
General Chairman, Minneapolis Committees,
Secretary, Dr. Tom B. Throckmorton Dr. Charles E. Proshek

ALL MEDICAL MEN AND WOMEN IN GOOD STANDING CORDIALLY INVITED

Managing-Director, Dr. William B. Peck*
Dr. Arthur G. Sullivan

Intensive Clinical and Didactic Program by World Authorities
The following is the list of members of the profession who will take part on the program :

Frank E. Adair, New York, N. Y.
Alfred W. Adson, Rochester, Minn.
John Alexander, Ann Arbor, Mich.
Walter C. Alvarez, Rochester, Minn.
W. Wayne Babcock, Philadelphia, Pa.
Lewellys F. Barker, Baltimore, Md.
Claude S. Beck, Cleveland, Ohio.

E. T. Bell, Minneapolis, Minn.
Herrman L. Blumgart, Boston, Mass.
Peter T. Bohan, Kansas City, Mo.
William F. Braasch, Rochester, Minn.
Carl D. Camp, Ann Arbor, Mich.
James G. Carr, Chicago, 111. /
Richard B. Cattell, Boston, Mass.
Russell L. Cecil, New York, N. Y.
Frederick Christopher, Evanston, 111.
Warren H. Cole, Chicago, 111.
Frederick A. Coller, Ann Arbor, Mich.
C. Donald Creevy, Minneapolis, Minn.
William R. Cubbins, Chicago, 111.
Elliott C. Cutler, Boston, Mass.
Walter E. Dandy, Baltimore, Md.
Robert S. Dinsmiore, Cleveland, Ohio
Claude F. Dixon, Rochester, Minn.
Daniel C. Elkin, Atlanta, Ga.

John F. Erdmann, New York, N. Y.

A. Carlton Ernstene, Cleveland, Ohio.
Ernest H. Falconer, San Francisco,
Calif.

Warfield M. Firor, Baltimore, Md.
John R. Fraser, Montreal, Canada
Henry J. Gerstenberger, Cleveland,
Ohio.

Harry S. Gradle, Chicago, 111.

Evarts A. Graham, St. Louis, Mo.
Roscoe R. Graham, Toronto, Canada.
Howard K. Gray, Rochester, Minn.
Robert G. Green, Minneapolis, Minn.
Russell L. Haden, Cleveland, Ohio.
Emile F. Holman, San Francisco, Calif.
Verne C. Hunt, Los Angeles, Calif.
Thomas E. Jones, Cleveland, Ohio.
Elliott P. Joslin, Boston, Mass.

Louis J. Karnosh, Cleveland, Ohio.
Chester S. Keefer, Boston, Mass.

H. Dabney Kerr, Iowa City, Iowa.

J. Murray Kinsman, Louisville, Ky.
Herman L. Kretschmer, Chicago, 111.
Frank H. Lahey, Boston, Mass.

N. Logan Leven, St. Paul, Minn.
William E. Lower, Cleveland, Ohio
Charles W. Mayo, Rochester, Minn.
John L. McKelvey, Minneapolis, Minn.
John C. McKinley, Minneapolis, Minn.
Irvine McQuarrie, Minneapolis, Minn.
John J. Moorhead, New York, N. Y.
George P. Muller, Philadelphia. Pa.
Clay Ray Murray, New York, N. Y.

John H. Musser, New Orleans, La.
Horace Newhart, Minneapolis, Minn.
Emil Novak, Baltimore, Md.

Frank R. Ober, Boston, Mass.

Eric Oldberg, Chicago, 111.

Paul A. O’Leary, Rochester, Minn.
Oliver S. Ormsby, Chicago, 111.
Ralph Pemberton, Philadelphia, Pa.
Dallas B. Phemister, Chicago, 111.
Isidor S. Ravdin, Philadelphia, Pa.
Hobart A. Reimann, Philadelphia, Pa.
Erwin R. Schmidt, Madison, Wis.
Elmer L. Sevringhaus, Madison, Wis.
George E. Shambaugh, Chicago, 111.
Leroy H. Sloan, Chicago, 111.

Thomas P. Sprint, Baltimore, Md.
Virgil P. W. Sydenstricker, Augusta,
Ga.

Willard O. Thompson, Chicago, 111.
Maurice B. Visscher, Minneapolis,
Minn.

Waltman Walters, Rochester, Minn.
Owen H. Wangensteen, Minneapolis,
Minn.

Soma Weiss, Boston, Mass.

Henry M. Winans, Dallas, Texas
Wallace M. Yater, Washington, D. C.
Hugh H. Young, Baltimore, Md.

HOTEL HEADQUARTERS HOTEL Hotel Committee: A. N. Bessesen, Jr., Chairman,

Hotel Nicollet - Hotel Radisson RESERVATIONS 2000 Medical Arts Bldg., Minneapolis, Minnesota.

A program will be mailed to every member of the medical profession in good standing in the United States and

Canada on or about September first.

Any member of the profession in good standing who does not receive a program, please write the Managing-

Director and one will be mailed.

COMPREHENSIVE SCIENTIFIC AND TECHNICAL EXHIBIT. SPECIAL ENTERTAINMENT FOR THE LADIES
•Deceased, August 20, 1941

September, 1941

Say you sazv it in the Journal of the Michigan State Medical Society

743

I

ANNOUNCEMENT

The Neuro-Psychiatric Institute of the Hartford Retreat announces the following ap-
pointments to its professional and assisting staffs :

PROFESSIONAL STAFF
Psychiatrist-in-Chief

C. Charles Burlingame, M.D., F.A.C.P.
Associate Psychiatrists

Leslie R. Angus, M.D.
H. Ryle Lewis, M.D.
Senior Psychiatrists

Edward L. Brennan, M.D.
William G. Young, M.D.
Josef A. Kindwall, M.D.
John W. Kinley, M.D.

Psychiatrists

Gordon H. Hutton, M.D.
Paul L. Phillips, M.D.
Ralph M. Stolzheise, M.D.
Robert L. Wagner, M.D.
Percy L. Smith, M.D.
Thornes G. Peacock, M.D.
Fellows in Psychiatry

Max Dayman, M.D.
Holmes E. Perrine, M.D.
Harry L. MacKinnon, M.D.
Laurence A. Hessin, M.D.
Robert S. Darrow, M.D.
Robert J. Hawkins, M.D.
Margaret A. Daley, M.D.

Psychologist

Blake D. Prescott, B.A., M.A., M.D.
Research Fellow in Psychiatry

Robert J. Streitwieser, M.D.
Research Associate in Psychiatry

John M. Cotton, B.Sc., M.D.
Research Associate in Endocrinology

Marjorie B. Patterson, B.S.
Research Associate in Electro-
encephalography

Herbert H. Jasper, A.B., M.A.,
Ph.D., es Sc.

Research Associate in Electro-
encephalography

Wladimir Theodore Liberson,
Ph.D., M.D.

Research Assistant in Allergy

Marjorie A. Darken, B.S., M.A.

Oculist

_ Harry St. C. Reynolds, M.D.
Gynecologist

Louis F. Middlebrook, M.D.
Roentgenologist

Gilbert W. Heublein, M.D.
Assistant Psychologist

Marie C. Morgan, B.A.

Dentist

George B. Odium, D.M.D.
Physician, Employees’ Health Service

William A. Wilson, M.D.
Joseph F. Jenovese, M.D.

THE ASSISTING STAFF

Nursing Supervisors (cont.)

Harold R. Towne, R-N.
Louise M. Perry, R.N.
Lois Cramb, R.N.

Research Technician

Elizabeth I. Gienandt, B.A.
Laboratory Technicians

Clair A. Reavey, B.A.
Mabel M. Bing You, Certificate
V. Wilson School

X-Ray Technician

Marion L. Kaul, Diploma
Northwest Institute

Pharmacist

Frank V. Zito, Ph.G.
Librarian, Jelliffe Library, and Translator
Mary B. Jackson, B.A., M.A.
Associate Librarian, Jelliffe Library

Katherine Malterud

Special Dietitian

Eleanore L. Breen, Certificate
Leslie School

Oral Hygienist

Patricia A. McCabe, O.H., Certificate
Columbia University
Chief of Medical Records Room

Ella C. Saunders
Correspondence Secretary

Lee A. Ferguson

Specie] Assistants to the Psychiatrist-
in-Chief

William M. Jennings
Thomas E. Murphy, LL.B.

Henrietta L. Hills

Resident Auditor

Albert W. Stevens

Comptroller

Alfred S. Hampson
Chief, Purchasing and Contract
Department

Helen R. Schait, Certificate
Pratt Institute

Personnel Manager

C. Pauline Kline

Employee Instructor

Anne F. Browne, R.N.
Employment Managers

Elizabeth B. Stephenson, B.A.

Doyle D. Henry, R.N.
Manager of Graduate Clubs

Helena E. Woodall, Skerry College,
. . , Plymouth, England

Assistant Manager of Graduate Clubs
. Sophie Coleman

Chief, Dietary Department

Armand L. Pelletier
Supervisor of Food Service

Helen G. Jacobs

Assistant to the Psychiatrist-in-Chief

Stella H. Netherwood, R.N.
2nd Assistant to the Psychiatrist-in-Chief
Mildred E. l.aBombard
3rd Assistant to the Psychiatrist-in-Chief
Ena Greenstreet
Secretaries to the Psychiatrist-in-Chief
Adelaide Ray
Rosalie Carroll

Introductor

Mary V. Cronin, R.N.
Assistant Introductors

Evelyn B. Dunlap, R.N.
Josephine LiVecchi, B.A.
General Director of Nursing

Elsie C. Ogilvie, R.N.
Director of Nursing

Mary E. Curtis, B.N., R.N.
Director of Nursing Education

Helen M. Roser, M.A., B.A., R.N.
Assistant Director of Nursing Education
Regina A. Driscoll, B.A., R.N.
Nursing Instructor

Edla C. Warner, R.N.
Nursing Supervisors

Mary Giannettino, R.N.
Alice Giannettino, R.N.
Margaret L. Fehr, R.N.
Erma D. Johnson, R.N.

FACULTY OF INSTRUCTORS
FOR GUESTS

Chairman, The Faculty of Instructors
for Guests

Blake D. Prescott, B.A., M.A., M.D.
Executive Officer, The Faculty of
Instructors for Guests

Constance Smithwick, R.N.
Associate Executive Officer, The Faculty
of Instructors for Guests and Chief
Instructor University Extension Courses
Angela T. Folsom, B.A., M.A.

Secretary

Barbara J. Gately, B.A.
Editor, Publication for Guests

Mary E. Burhoe, B.A.
Art Editor, Publication for Guests

Carolyn C. Bronson,
Art Students League of New York
Social Director

Ruth D. Tuttle, B.A., M.A.
Instructors, University Extension
Courses

Margaret L. Adams, B.A., M.A.
Margaret F. Head, B.A.
Efiie Jane Sutherland, B.A.
Instructor, French

Marguerite Yourcenar, B. es L.

Librarian, Guest Library

Phoebe L. Adams, B.A
Consulting Librarian, Guest Library

Mary Alice Thoms, B.A
Instructor, Horticulture

Robert F. Stevens, B.S., M.S.
Instructors, Current Events

Ward E. Duffy, B.A., B.Lit
John W. Colton, B.A., B.Lit.
Instructors, Physical Eklucation

Joseph E. Roche, B.A
Frank Kubin, B.A
Alice F. Richards, B.S.
Frances E. Guild, B.S.
Instructor, Sculpturing

Frances L. Wadsworth,
Student of a Rodin pupil
Instructor, Painting and Modelling

Catherine D. Cardamon, Certificate
Pratt Institute

Instructor, Painting and Drawing

Helen Faude, Yale Art School
Instructor, Appreciation of Axt

A. Everett Austin, Jr., B.S.
Instructor and Modiste

Doris Runshaw

Instructor, Shorthand and Commercial
Courses

Martha L. Blake, Certificate
Bay Path Institute

Instructor, Bridge

Theodosia Van Norden Emery,
Master of Bridge and Director
Culbertson National Studios
Instructor, Dancing

Doris Gibbons,
Russian School of Ballet Dancing
Instructors, Arts and Crafts

Bertha M. White, Certificate
Boston School of Handicrafts
Jean P. Harris, Certificate
Pratt Institute

Instructors, Manual Arts

Alexander Koszalka
N. Grant Kelsey, Certificate
Pratt Institute

Instructor, Dietetics

Helen L. Ronan, Certificate
Pratt Institute

Instructor, Music Appreciation

Paul Vellucci, Director
Hartford School of Music
Instructor, Music, Organ and Piano

, Venila B. Colson, B.A., M.A
Instructor, Music, Vocal

Josephine S. Koch,
Yale School of Music

Instructor, Cello

Katherine H. Howard, Diploma
Royal School of Music, Berlin
Instructors, Violin

Ruth A. Ray,
Hartford School of Music
Emma S. Miller

Instructor, Braille

Ethel M. Law, B.Ed.
Instructor, Lip Readii^

Eveline Dunbar, Certificate
Clark School
Training Class for Teachers
Instructors, Beauty Culture

Dorothy L. Allen, Certificate
Schulz Training School
Helen K. Stevens,
Harper Method Training
Personal Shopper

Virginia Bragan

Assistant Shopper

M. Emilienne Dufresne
Chief Physiotherapist

Charles C. Canivan, R.N., P.T.
Physiotherapists

Ruth E. Manion, R.N., P.T.
William E. Groff, R.N.
Virginia M. Smith, R.N.

O^'chestras

Institute’s Chamber Music Orchestra
White’s Cavaliers
Jones’ Music Masters

THE NEURO-PSYCHIATRIC INSTITUTE OF THE HARTFORD RETREAT

200 Retreat Avenue Hartford, Connecticut

Private endowed, non-profit institution
Founded in 1822

744

Jour. M.S.^t.S.

1866

1941

7Sth

THE BATTLE CREEK SANITARIUM

a general medical institution, fully equipped for
diagnostic and therapeutic services.

Paying special attention to physical therapy
and diet in the treatment of chronic disorders
especially of the gastro-intestinal tract, the ane-
mias, arthritis, circulatory disorders, diabetes and
other degenerative diseases.

Extensive laboratories with modern scientific
equipment for diagnostic and research purposes,
including the newly organized Endocrine and
Vitamin Assay Laboratories.

Physicians are invited to write for full information

Address i

Dept. 3215 THE BATTLE CREEK SANITARIUM 9 Battle Creek, Mich.

It makes their regular check-ups
"fun” by giving youngsters some
wholesome CHEWING GUM

It’s such an easy, thoughtful gesture to always offer
your little patients some delicious Chewing Gum
while they’re waiting or when they leave the office.
They just love it — and it makes a big hit with
adults, too. And for such a small cost this one,
friendly, little act goes a long way in winning extra
good will and affection. Besides, as you know, the
chewing is an aid to mouth cleanliness as well as
helping to lessen tension. Enjoy chewing Gum,
yourself Get a good month’s worth for your
office today.

There's a reason, a time
and place for Chewing Gum

NATIONAL ASSOCIATION OF CHEWING GUM MANUFACTURERS, STATEN ISLAND, NEW YORK

745

September, 1941

Say you saw it in the Journal of the Michigan State Medical Society

^ MICHIGAN’S DEPARTMENT OF HEALTH

HENRY A. MOYER, M.D., Commissioner, Lansing, Michigan

MALARIA IN MICfflGAN

Malaria may return to Michigan as an endemic dis-
ease of some importance as a result of increased migra-
tion between Michigan and southern states. In pioneer
days, malaria was common in the state. The malaria
area of the country is gradually extending northward
and native malaria has been found in some sections
in Michigan, but now there is a possibility of a marked
increase in infection due to the national defense and
Army training programs. No increase in reported
cases has occurred, however. Industrial jobs are ap-
parently attracting southern families, and the Army is
sending drafted men from Michigan into southern camps
and bringing into the state men from southern malarial
regions.

In view of this new situation the Department sug-
gests to physicians an increasing likelihood of their
finding malaria, especially in migrant families from
the South or in persons returned from the South. Last
year, 60 cases of malaria were reported in Michigan,
and in the last five years, 379 cases. The supposition
has been that in recent years all malaria cases in
Michigan have been imported, but epidemiological
studies have shown that in some instances where south-
ern families have lived in the state malaria has been
spread locally.

The Anopheles quadrimaculatus mosquito which car-
ries malaria infection is present in certain areas of
Michigan. It is a common, night-biting mosquito which
lives either about homes or in woods. In all cases
of malaria, in addition to treatment for the patient,
the home should be screened to keep infection from
mosquitoes.

SIXTY-FIVE COUNTY HEALTH UNITS

In the first six months of 1941, three new full-time
health departments were established in Michigan. The
Shiawasse county department was established January 1,
and departments were established July 1 in Washtenaw
and Kalamazoo counties. Only 18 counties are now
without full-time health department services.

The Kalamazoo unit is Michigan’s first county-city
health department. The director is Dr. I. W. Brown,
who headed the Kalamazoo city health department and
who has just returned from a year’s study in public
health at Johns Hopkins.

In several instances in the state, full-time city and
county health departments are operating independent!}',
but the Kalamazoo unit will be the only one to have
a single director and to provide services equally to city
and county residents.

Washtenaw’s new unit is headed by Dr. Otto Engelke,
who has been associated with the W. K. Kellogg Foun-
dation in Calhoun county for more than a year. The
appointment became effective July 16.

Oakland county’s health department, established De-
cember 1, 1926, was the first full-time county unit in
the state. That was a short time before the 1927 legis-
lative act providing for county departments and two
years before the amendment of 1929 which gave state
financial aid to county and district health departments.
Financial support has been given to county health
units by the W. K. Kellogg Foundation (starting in
1931) and by the Children’s Fund of Michigan (starting
in 1929). The number of counties with their own or
with district health services totaled 21 by 1935, and
62 by the end of 1940. The number is now 65.

(DUE TO NEISSERIA GONORRHEAE)

of!,

ilver Picrate,
Wyeth, has a convincing record of
effectiveness as a local treatment for
acute anterior urethritis caused by
Neisseria gonorrheae.^ An aqueous
solution (0.5 percent) of silver pic-
rate or water-soluble jelly (0.5 per-
cent) are employed in the treatment.

Acomplefe techniqueof treatment and literaturewill besentupon request

♦Silver Picrate is a definite crystalline compound of silver and picric acid.
It is available in the form of crystals and soluble trituration for the prepara-
tion of solutions, suppositories, water-soluble jelly, and powder for vaginal
insufflation.

1. Knight, F., and Shelanski,
H. A., "Treatment of Acute Ante-
rior Urethritis with Silver Picrate,”
Am. J. Syph., Gon. & Ven. Dis.,
23, 201 (March), 1939.

JOHN WYETH & BROTHER, INCORPORATED, PHILADELPHIA

746

Say you sazv it in the Journal of the Michigan State Medical Society

Jour. M.S.-M..^.

I

MICHIGAN’S DEPARTMENT OF HEALTH

jSMALLPOX CASES INCREASE

i More smallpox was reported in Michigan in six
months this year than in the whole of last year.
:For 1940, the year’s total was 76 reported cases.
iFrom January through June of 1941, 90 cases were
Ireported.

j, MSMS

fPOIJOMYEUTIS LOW IN JULY

1 Infantile paralysis cases reported in July to the
jMichigan Department of Health totaled 24 compared
fwith 28 in July of 1940. Last year, the record
lepidemic came on very swiftly in August when
more than 300 cases were reported and went to
a peak in September when more than 500 cases
were reported.

MSMS —

SYPmUS TESTS REACH NEW HIGH

! Blood tests for syphilis in public and private labora-
tories in Michigan are now running more than 3,000
a day. The number of blood tests and other laboratory
examinations for syphilis (darkfields and spinal fluids)
went beyond 100,000 for the first time in May, when
the total was 100,197.

Of this total, 44,534 tests were done by the four
Michigan Department of Health laboratories, 21,336
by city health department laboratories aided financially
by the state, and 34,327 by private, registered labora-
tories.

Never before has there been in the state such gen-
eral and effective use of the blood test to discover
syphilis infection. There are several reasons. Every
man called for physical examination by Selective Serv-
ice is given a blood test, every couple applying for a
marriage license must have blood tests, and so must
all prospective mothers. In addition, it is becoming
policy in hospitals to give a blood test to every patient,
physicians are using them increasingly, and factories
are beginning to ask for blood tests on new workers.

Wartime conditions have greatly influenced the con-
trol methods used against venereal disease. Reporting
of cases to health departments was required by law
after the draft of 1917 had shown a surprising amount
of infection, and more than 20 years later another
Selective Service law is putting new emphasis on blood
tests, whether or not there is any suspicion of in-
fection.

Three things are necessary in the control of syphilis,
and in all three Michigan is a leader among the states.
Reporting of cases and blood testing are two of the
essentials in control. The third is treatment. The state
health laboratories do the tests without charge for
physicians, and the State Health Department supplies
free drugs to physicians for treatment of syphilis
patients. Much progress is being made in bringing in-
fected persons under treatment. For example, names
of men rejected for the Army because of syphilis are
being reported to health department so that treatment
can be arranged.

Michigan’s infection rates are low as shown by tests
required of brides and grooms, of prospective mothers,
and of men called by Selective Service. Among drafted
men, the syphilis rate is less than two per cent. Among
applicants for marriage licenses, it is about one per cent.
Among prospective mothers, it is well under one per
cent.

MSMS —

The progressive Doctors of Medicine in Michi-
gan will be present at the Annual Meeting of the
Michigan State Medical Society, September 17, 18,
and 19 in Grand Rapids.

September, 1941

Each sip of smooth, satisfying
Johnnie Walker is a taste-adven-
ture— always enjoyable, always
welcome.

★

irs SENSIBLE TO STICK WITH

Johnnie

f^LKER

BLENDED SCOTCH WHISKY

CANADA DRY GINGER ALE, INC., NEW YORK, N. Y.
SOLE IMPORTER

Say you saw it in the Journal of the Michigan State Medical Society

747

-K COUNTY AND PERSONAL ACTIVITIES -»<

Henry R. Carstens, M.D., president-elect of the Michi-
gan State Medical Society, brought the greetings of the
Michigan Medical Profession to the Michigan Phar-
maceutical Association at its annual convention in De-
troit, August 19.

* * *

Richard Burke, M.D., of Palmer, and Wm. H. Alex-
ander, M.D., of Iron Mountain, were chosen as Presi-
dent and President-elect, respectively, of the Upper
Peninsula Medical Society at its July meeting in Iron-
wood. The 1942 meeting will be held in Marquette.

The Fourth Annual Forum on Allergy will be held
in Detroit, January 10-11, 1942. For program and de-
tails, write Jonathan Forman, M.D., 1005 Hartman
Theatre Bldg., Columbus, Ohio.

Frank L. Rector, M.D., Chicago, has been appointed
as Field Representative in Cancer by the Cancer Control
Committee of the Michigan State Medical Society, ef-
fective September 15. Dr. Rector will be under the
joint sponsorship of the State Medical Society and of
the Michigan Department of Health. Dr. Rector comes
to Michigan well qualified by a wealth of experience
and training, having served for many years as Field
Representative for the American Society for the Con-
trol of Cancer. His work of informing the Michigan
medical profession and educating the laity concerning
cancer control should be filled with success.

ALL MEMBERS WELCOME AT
DELEGATES’ MEETINGS

Members of the Michigan State Medical So-
ciety are cordially invited to attend the special
meeting of Delegates, Monday evening, Septem-
ber 15, 8:00 p.m., and the all-day session of Tues-
day, September 16, beginning at 9 :00 a.m.

The business of the Society is transacted by the
House of Delegates. This body makes important
decisions on matters affecting the daily practice
of every doctor whose interest will be best indi-
cated by his presence at Delegates’ meetings.

Remember, You Are Welcome eind Urged
to Attend

of the American Medical Association, issue of July
19, 1941.

F. P. Currier, M.D., Charles H. Frantz, M.D., and
Ray Vander Meer, M.D., all of Grand Rapids, are
authors of an article entitled “Reduction of Growth
Rate in Gigantism Treated with Testosterone Propion-
ate’’ which appeared in The Journal, AM A, issue^
of August 16, 1941.

“Industrial Health Marches on: Chairman’s Ad-

dress’’ by C. D. Selby, M.D., appeared in the Journal

Polio Consultation Service. — The ^Michigan Crippled
Children Commission will again establish consultation
service to doctors of medicine who desire same fort
cases or suspected cases of poliomyelitis where the fam-|
ily is financially unable to provide for this service. Thek

MARTIN-HALSTED CO

anu

ij,

Below knee limb
with ball bearing
ankle and knee
joints

English Willow or
Metal Legs

Felt, Wood and Sponge
Rubber Feet

Abdominal Belts, Trusses, Elastic Stockings,
Crutches, and Orthopedic Braces.

Oldest and Largest in the State of Michigan.
Over 30 Years in Detroit.

Phone or write us, a representative ivill call
on you.

Above knee limb
with Pelvic Belt.

300 Woodward Avenue Detroit, Michigan

(Corner Woodbridge)

Cadillac 5093

748

Say you saw it in the Journal of the Michigan State Medical Society

Jour. M.S.M.S.

COUNTY AND PERSONAL ACTIVITIES

doctor should contact the Secretary o£ his County Medi-
cal Society and request a consultant, indicating the con-
sultant of his choice in that area. The Secretary will
telegraph the Commission which in turn will notify the
consultant authorizing consultation with the family
physician.

If polio becomes prevalent in your community, inform
f the Commission immediately.

^ ^ >{C

1 Advise the editor of your newspaper that you will be
I in Grand Rapids for the 76th Annual Meeting of the
' Michigan State Medical Society, September 17, 18, 19,

; 1941.

I Bring your M.S.M.S. Membership Card, to facilitate
! registration.

1 The scientific and technical exhibit of 110 spaces is
[ an educational opportunity of unusual interest and
I scope.

Remember the dates, September 17, 18, 19, 1941, Civic
Auditorium, Pantlind Hotel, Grand Rapids.

* * *

The Wayne County Medical Society’s courses in
Anatomy, to be given at Wayne University College of
Medicine, are as follows :

Section I — Back, Thorax and Abdomen — Sept. 10 to
Nov. 26, 1941

Section II — Pelvis — Dec. 3 to Dec. 31, 1941
Section III — Extremities — Jan. 7 to Mar. 11, 1942
Section IV — Head and Neck — March 18 to June 3, 1942
^ ^

The Second American Congress on Obstetrics and
Gynecology will be held in St, Louis, Missouri, on April
6-10, 1942. Plans are progressing rapidly for the pro-
gram. E. D. Plass, M.D., is Chairman of the Program
Committee and Wm. F. Mengert, M.D., is Secretary.
Chairmen of the subcommittees are as follows: Ralph
A. Reis, M.D., Medical Section ; Miss Georgia Hukill,
Nursing Section; R. C. Buerki, M.D., Hospital Section;
Edwin C. Daily, M.D., Public Health Section ; and Clair
E. Folsome, Educators Section.

The Scientific and Educational Exhibits Committee is
headed by H. C. Hesseltine, M.D., with Charles Gal-
loway, M.D., as Secretary.

^

Abraham Lec-nhouts, M.D., of Holland was honored
by his brothers and sisters and close life-long friends
on the completion of fifty years in the active practice
of medicine and his 75th birthday, August 4. Doctor
Leenhouts graduated from the University of Michigan
Medical School and began practice in South Holland,
Illinois. After three years he moved to Chicago where
he practiced and took postgraduate work in eye, ear,
nose and throat at Chicago University. In 1901 he
came to Holland where he has practiced since. Last
June Doctor Leenhouts was inducted into the Emeritus
Club at the University of Michigan, an honorary so-
ciety for graduates of fifty j^ears.

^ *

John A. Alexander, M.D., Ann Arbor, professor of
surgery. University of Michigan Medical School, and
surgeon in charge of the division of thoracic surgery
at University Hospital, was awarded the Trudeau Med-
al of the National Tuberculosis Association. Doctor
Alexander graduated at the University of Pennsylvania
School of Medicine in 1916. He was president of the
American Association for Thoracic Surgery in 1935 and
of the Michigan Tuberculosis Association, 1938-39. He
is author of “The Surgery of Pulmonary Tuberculo-
sis” published in 1925 and of “The Collapse Therapy of
Pulmonary Tuberculosis,” 1937. He was awarded the
Samuel D. Gross prize of the Philadelphia Academy of
Surgery in 1925 and in 1930 the Henry Russell award
of the University of Michigan was made to him.

September, 1941

FAITHFULLY YOURS
FOR THESE MAM USES

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“Ciba” has honestly earned a position
of importance as a local anesthetic of
prolonged, intense action in rhino-laryng-
ology, urology, ophthalmology, derm-
atology and dentistry.

For Infiltration Anesthesia, non-
narcotic Nupercaine (alpha-butyl-oxycin-
choninic acid diethyl -ethylene -diamide
hydrochloride) is firmly entrenched as a
dependable product.

For Spinal Anesthesia, Nupercaine has
garnered a reputation second to none,
with impressive papers in the field ob-
tained during the past several months.

The relative low toxicity of Nupercaine
when properly used, and its many other
advantages, have been the subject of
almost 2,000 articles in the professional
press. . . . Literature cheerfully furnished.

TABLETS • POWDER • SOLUTION • AMPULES

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Word “Nupercaine” identifies the
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acid diethyl-ethylene-diamide hydro-
chloride of Ciba’s manufacture.

CIBA PHARMACEUTICAL PRODUCTS, Inc.

SUMMIT • NEW JERSEY

Say you saw it in the Journal of the Michigan State Medical Society

749

COUNTY AND PERSONAL ACTIVITIES

Main Entrance

SAWYER SAMTDRIUM

White Oaks Farm

Marion, Dhio

For the treatment of
Nervous and Mental Diseases
and Associated Conditions

Licensed for

The Treatment of Mental Diseases
by the Department of Public Welfare
Division of Mental Diseases
of the State of Ohio

Accredited by

The American College of Surgeons
Member of

The American Hospital Association
and

The Ohio Hospital Association

Housebook giving details, pictures,
and rates will be sent upon request.
Telephone 2140. Address,

SAWYER SAIVATDRIUM
White Daks Farm
Marion, Ohio

Council and Committee Meetings 1

1. Thursday, August 7, 1941 — Executive Committee ofl

The Council, Ann Arbor — 4:00 p.m. '

2. Friday, August 8, 1941 — Maternal Health Committee
Hotel Statler,' Detroit — 11 a.m.

3. Monday, September 8, 1941 — Discussion Conference
Leaders — Warded Hotel, Detroit — 6 p.m.

4. Sunday, September 14, 1941 — Syphilis Control Com-
mittee— Pantlind Hotel, Grand RapMs — % p.m.

5. Monday, September 15, 1941 — The Council — Service
Club Lounge, Pantlind Hotel, Grand Rapids — 3 :00
p.m.

NOTICE

The Michigan Crippled Children Commission is
continuing the policy of restricting the removal
of tonsils, and is confining approvals to cases
complicating the following conditions :

Cervical T.B. adenitis
Chorea
Endocarditis
Mastoiditis

Otitis media (chronic)

Rheumatic fever

Also included in the restricted program are :
Hernia (except strangulated)

Circumcision

Adenoidectomy

Orchidopexy

Glasses

The approval of glasses is limited to post-oper-
ative eye afflictions such as strabismus and cat-
aract.

1

Attention, physicians who treat men who have been
injured while working for contractors on government
work. The following bulletin was sent on July 24, 1941,
to all contractors by the Office of Construction Quarter-
master of the War Department :

“Effective this date you are instructed to direct ;
all contractors and/or their insurance carriers, and
through either or both of them, all civilian physi-
cians to whom any of the contractors’ employes
may be sent for treatment on injuries sustained '
while at work, that tetanus antitoxin will not be
administered to any such injured employe with-
out first making the usual skin test to determine l
the patient’s reaction to the serum. In the event 1
that a positive reaction develops and antitoxin is *
still necessary, the patient shall be removed to a |
hospital for treatment indicated in the circum- J
stances.’’ ]

* * * j

All physicians will receive in September an informa- •
tion card from the headquarters office of the American
Medical Association asking for certain data for use in j
compiling the Seventeenth Edition of the American ,
Medical Directory.

Physicians are urged to fill out these cards promptly
and return them to the AMA in Chicago in order that
the 1942 edition of the AMA Directory may be as ac-
curate as possible. The Directory is one of the most
important contributions of the American Medical As-
sociation to the work of the medical profession in the
United States. It has been especially valuable in the
medical preparedness program. Physicians are urged to
state whether or not they are on extended activ'e duty
for the medical reserve corps of the United States
Army and Navy. Cards should be filled out and re-
turned promptly whether or not a change has occurred.
Physicians who do not receive a card before October
first should write at once to the AMA, 535 North Dear-
born Street, Chicago, and request a duplicate.

Jour. M.S.M.S.

750

Say you saw it in the Journal of the Michigan State Medical Society

COUNTY AND PERSONAL ACTIVITIES

The Michigan State Pharmaceutical Association is
one of five associations which are sponsoring a series
of institutional broadcasts over radio station WLW,
Cincinnati. From September 15 to 28, inclusive, the
following announcement which is of interest to all
physicians will be made ;

“The druggists of Ohio, Kentucky, Indiana, West
Virginia, Michigan and other states invite you to al-
ways shop in their stores for the needs of your family.

“Harsh winter will be here shortly and your friendly
druggist suggests that your family have a physical
check-up by your physician to make sure that they are
prepared for its rigors ! Your druggist — always the
dependable ally of your physician — will be glad to
supply the vitamins or other strength-building items
prescribed by the latter to assist in having a sickness-
free winter.

“So — consult your physician soon — this foresight
will add so much to your enjoyment of the good times
throughout the holidays and later. Enjoy winter by
keeping well and fit!”

^ 3^

ASSOCIATE FELLOWS IN POSTGRADUATE
EDUCATION

The following doctors of medicine are eligible for
certificates of Associate Fellowship in Postgraduate
Education, Michigan State Medical Society, 1941.

The State Society congratulates these physicians on
their successful completion of the formal four years’
continuation work arranged by the M.S.M.S. Committee
on Postgraduate Medical Education. The certificates of
award will be mailed to Fellows shortly after the State
Society Convention in Grand Rapids.

Kent A. Alcorn, M.D., Bay City; William K. Anderson, M.D.,
Saginaw; John N. Asline, M.D., Essexville.

Ulysses S. Bagley, M.D., Saginaw; Robert Bailey, M.D., St.
Clair Shores; William R. Ballard, ‘M.D., Bay City; Paul H.
Bassow, M.D., Ann Arbor; Harvey C. Bodmer, M.D., Kala-
mazoo; Leon C. Bosch, M.D., Grand Rapids; Lewis J. Burch,
M.D., Mount Pleasant; Robert A. Burhans, M.D., Lansing;
Earle J. Byers, M.D. Grand Rapids.

Elisha W. Caster, M.D., Mount Clemens; Henry G. Chall,
M.D., Detroit; William E. Clark, M.D., Mason; Cecil Corley,
M.D., Jackson.

Ernest W. Dales, M.D., Grand Rapids; Leon DeVel, M.D..
Grand Rapids.

John M. Edmonds, M.D., Horton.

Joseph H. Failing, M.D., Ann Arbor; Foster A. Fennig,
M.D.. Marquette; John V. Fopeano, M.D., Kalamazoo; Wilbur
W. Fosget, M.D., Lansing; William L. Foust, M.D., Grass
Lake; Edson H. Fuller, Jr., M.D., Grand Rapids; Edward T.
Furey, M.D., Detroit.

Henry C. Galantowicz, M.D., Detroit; John L. Gates, M.D.,
Ann Arbor; Cornelius J. Geenen, M.D., Grand Rapids; Joseph
W. Gething, M.D., Battle Creek.

Herbert O. Helmkamp, M.D., Saginaw; S. Franklin Horowitz,
M.D., Bay City.

Elwin B. Johnson, M.D., Allegan; Harrison H. Johnson, 'M.D.,
Allegan.

Alfred H. Keefer, M.D., Concord; Marceine D. Klote, MD
Detroit.

Maurice J. Lieberthal, M.D., Ironwood; William R. Lyman
M.D., Dowagiac. ’

Charles L. MacCallum, M.D., Midland; Robert McGregor
M.D., Saginaw; J. Earl McIntyre, M.D., Lansing. ’

Edward H. Meisel, M.D., Midland; Clifton E. Merritt, M.D.
!Manton; Edward A. Miller, M.D., Berrien Springs; Neal R
Moore M D., Bay City; George F. Muehlig, M.D., Ann Arbor;
Fred E. Murphy, M.D., Cedar; Scipio G. Murphy, MD De-
troit. ’

Frank O. Novy, M.D., Saginaw.

James Ar Olson, M.D., Flint; James J. O’Meara, M.D.
Jackson; William J., O’Reilly, M.D., Saginaw.

Homer A. Phillips, M.D., Saginaw; Edward A. Pillsbury,
M.D., Frankenmuth; Ray A. Pinkham, M.D., Lansing

Lyle C. Shepard, M.D., Otsego; Joseph H. Sherk, M.D., Mid-
Wenadine Snow, M.D., Ypsilanti; G. Howard Southwick
M.D., Grand Rapids; Ronald W. Spaulding, M.D., Gobles-
®ay City; Arthur W. Strom, M.D.,
xlulsdale; Harold C. Swenson, M.D., Grand Rapids.

Cliffo^ B. Taylor, M.D., Albion; Pius L. Thompson, M.D
Grand Rapids; Alfred A. Thompson, M.D., Mount Clemens-
Trudeau, M.D., Rogers City; Ray V. Tubbs, M.D., Bliss’-

field.

Edwin P. Vary, M.D., Flint.

Lee E. Westcott, M.D., Kalamazoo; George B. Wickstrom,
M.D., Munsing.

Alois L. Ziliak, M.D., Bay City.

September, 1941

en/cn^

^erntor

'i

Professional

Pharmacy

Doctors of Medicine—
Obtain your drug needs
from a Pharmacist who
knows the action, proper
dosage of drugs, and is
familiar with the latest drug
research.

Fair Rate Prices

Professional Pharmacy

Trahan Brothers

Davidson Bldg.-Bay City^ Mich.

751

COUNTY AND PERSONAL ACTIVITIES

I

The Academy of O phthalmology and Otolaryngology
will hold its 46th annual meeting at the Palmer House,
Chicago, October 19-23, 1941. Frank R. Spencer, M.D.,
Boulder, Colo., is president of the Academy. A feature
of the meeting this year will be a symposium on vertigo
with Francis H. Adler, M.D., Philadelphia, representing
ophthalmology; Wm. J. McNally, M.D., Montreal, rep-
resenting otolaryngolo^ ; and Bernard Alpers, M.D.,
Philadelphia, representing neurology. Among the pa-
pers to be presented during the week will be the fol-
lowing: “Surgical Treatment of Vascular Diseases of
the Orbit” by Alfred W. Adson, M.D., Rochester,
Minn. ; “Allergy and Ophthalmology” by Albert N. Le-
Moine, M.D., Kansas City; “Operative Results in 200
Cases of Convergent Strabismus” by John H. Dun-
nington, M.D., and Maynard Wheeler, M.D., New
York; “Otolaryngological Problems and the Weather”
by W. F. Petersen, M.D., Chicago ; “The Problem of
Preventing Partial or Total Loss of Vision in Glauco-
ma Patients of Eye Clinics” by Mark J. Schoenberg,
M.D., New York; “Practical Uses of Chemotherapy in
Ear, Nose and Throat Work” by Charles T. Porter,
M.D., Boston; “Treatment of Sinus Diseases in Chil-
dren” by Alfred J. Cone, M.D., St. Louis; “The Use
of Urea in Certain Diseases of the Ears, Nose and
Throat” by Rea E. Ashley, M.D., San Francisco; and
“What Otologists Can Do For Defective Hearing” by
Frederick T. Hill, M.D., of Waterville, Maine.

Perry Goldsmith, M.D., professor of otolaryngology
in the University of Toronto, Faculty of Medicine, will
be the academy’s guest of honor this year.

Officers of the academy in addition to Doctor Spencer
are Ralph Irving Lloyd, M.D., Brooklyn, President-
elect; Everett L. Goar, M.D., Houston, Texas; James
Milton Robb, M.D., Detroit, and Ralph O. Rychener,
M.D., Memphis, vice presidents ; and Secord H. Large,
M.D., Cleveland, comptroller, Wm. P. Wherry, M.D.,
Omaha, is executive secretary-treasurer.

INTERNATIONAL ASSEMBLY

This year’s International Assembly of the Inter-State
Postgraduate Medical Association of North America
will be held in the public auditorium, Minneapolis, Min-
nesota, October 13, 14, 15, 16 and 17.

The high standing of the medical profession of Min-
neapolis, combined with the unusual clinical facilities
of its great hospitals and excellent hotel accommoda-
tions, make this city an ideal place in which to hold
the Assembly.

The officers of the Inter-State Postgraduate Medical
Association, those of the Hennepin County Medical
Society and the Minnesota State Medical Association,
extend a very cordial invitation to all members of the
profession in good standing to attend the Assembly.

A full program of scientific and clinical sessions will
take place each day and evening of the Assembly, start-
ing at 8:00 o’clock in the morning.

In cooperation with the Hennepin County Medical
Society, the Minnesota State Medical Association and
the Minneapolis Civic and Commerce Association, a
most excellent opportunity for an intensive week of
postgraduate medical instruction is offered by approxi-
mately eighty-five distinguished teachers and clinicians
from different parts of the United States and Canada
who are honoring the Assembly by contributing to the
program. The speakers and subjects have been care-
fully selected by the program committee.

Pre-assembly and post-assembly clinics will be con-
ducted, free of charge, in the Minneapolis hospitals on
the Saturdays previous to, and following the Assembly,
for visiting members of the profession.

Ferguson -Droste- Ferguson Sanitarium

•i*

Ward S. Ferguson, M. D. James C. Droste, M. D. Lynn A. Ferguson, M. D.

•i*

PRACTICE LIMITED TO
DIAGNOSIS AND TREATMENT OF

DISEASES OF THE RECTUM

*

Sheldon Avenue at Oakes

GRAND RAPIDS, MICHIGAN

4*

Sanitarium Hotel Accommodations

752

Jour. M.S.M.S.

IN MEMORIAM

Excellent scientific and commercial exhibits of great
interest to the medical profession will be an impor-
tant part of the Assembly. These exhibits will be open
to members of the medical profession in good standing
without paying the registration fee.

The registration fee for the scientific and clinical
sessions will be $5.00.

Members of the profession who can possibly arrange
to attend the Assembly cannot afford to miss it.

With a great deal of pride and satisfaction, we call
your attention to the list of distinguished teachers and
clinicians who are to take part on the program and
whose names appear on page 743 of this Journal.

Roscoe R. Graham, President, Toronto, Canada.

George W. Crile, Chairman, Program Committee,

Cleveland, Ohio.

William B. Peck, Managing-Director, Freeport, 111.

3ln jHcntotriam

J. William Gustin of Bay City was born in 1876
and was graduated from the Detroit College of Medi-
cine in 1903 and the University of London, Ontario.
Dr. Gustin retired two years ago because of ill health.
He died in Billings Hospital, Chicago, Illinois, on July
21, 1941.

* * *

Hermon Harvey Sanderson of Detroit was born
in Sparta, Ontario, in 1869. He was graduated from
Toronto University in 1892 and began practice with his
father, Robert Lyon Sanderson, M.D., in Sparta, On-
tario, where he remained one year, then moved to
Windsor, where he practiced until 1912 and then moved
to Detroit. He studied in London, England, and Vien-
na, preparing for his specialty of eye, ear, nose, and
throat. He was chief of the Department of Ophthal-
mology at the Harper Hospital for many years. He
was a member of the American College of Surgeons
and an honorary member of the Detroit Ophthalmologi-
cal Club. Doctor Sanderson died July 1, 1941.

* * *

G. Reginald Smith of Port Huron was born in
Carsonville, Michigan, in 1881 and was graduated from
the Detroit College of Medicine in 1903. During the
World War, Doctor Smith served as assistant to An-
gus McLean, M.D., who established Harper Unit No.
7 in France. Doctor Smith was past president of the
St. Clair County Medical Society. He died July 21,
1941, in Harper Hospital, Detroit.

%

Claude W. Walker of Iron Mountain was born
near Scranton, Pa., in 1876, and was graduated from
the University of Pennsylvania Medical School in
1901. He took advanced work in eye, ear, nose and
throat at the New York Postgraduate College and at
Johns Hopkins University. Later he practiced medi-
cine at Schenectady, N. Y., Milwaukee and Green Bay,
Wisconsin. Doctor Walker enlisted as a lieutenant in
the U. S. Army Medical Corps in 1917. He served
overseas and was promoted to the rank of major Re-
turning to the United States after the Armistice he
received his honorable discharge in 1919. In 1920 Dr
Walker established an office in Iron Mountain where
he practiced until the time of his tragic death Dr
Walker together with Mrs. Walker was killed when
his auto crashed on his return trip from the Upper
Peninsula Medical Society Meeting on July 18.

September, 1941

THE COMPLETE
FISCHER LINE

I See the latest Fischer equipment in Booth No. I
B-16 at the Grand Rapids Convention

H. G. FISCHER & CO. were pioneers in building
x-ray and electro-surgical-medical apparatus.
Today they are one of the largest manufacturers
and FISCHER apparatus is well and favorably
known, not only in the United States but around
the world.

There is a reason. Every piece of FISCHER
^ equipment must first of all equal or exceed
in performance every competing unit, designed
for the same purpose, regardless of price. Sec-
ond, the unit itself must be priced at the lowest
point consistent with quality manufacture. Per.
formance of all FISCHER equipment is guaran-
teed.

The complete FISCHER line includes many
^ models of shockproof x-ray apparatus, both
medical and dental, short wave generators,
galvanic and wave generators, ultraviolet and
infrared generators, other apparatus, acces-
sories and supplies. More than 65,000 physi-
cians, hospitals, clinics and universities in the
United States insist on FISCHER apparatus.

Full information on any unit of
FISCHER apparatus will be sent
on request, promptly by return
mail. Write or use postcard. No
obligation.

M. C HUNT

Dealer Representative

H. G. FISCHER & CO.

502 Maccabee Blcig. Detroit, Mich.

753

OR safety and reliability use composite Radon seeds in your
cases requiring interstitial radiation. The Composite Radon
Seed is the only type of metal Radon Seed having smooth,
round, non-cutting ends. In this type of seed, illustrated
here highly magnified. Radon is under gas-tight, leak-proof
seal. Composite Platinum (or Gold) Radon Seeds and
loading-slot instruments for their implantation are available
to you exclusively through us. Inquire and order by mail,
or preferably by telegraph, reversing charges.

THE RADIUM EMANATION CORPORATION

GRAYBAR BLDG. Telephone MO 4-6455 NEW YORK, N. Y.

Cook County

Graduate School of Medicine

(In Affiliation with Cook County Hospital)

Incorporated not for profit
ANNOUNCES CONTINUOUS COURSES

SURGERY — Two Weeks’ Intensive Course in Surgical
Technique with practice on living tissue, starting
every two weeks. General Courses One, Two, Three
and Six Months; Clinical Courses, Special Courses.
Rectal Surgery every week.

MEDICINES— Two Weeks’ Intensive Course starting
October 6th. Two Weeks’ Course in Gastro-Enterol-
ogy, starting October 20th. One Month Course in
Electrocardiography and Heart Disease every month,
except December.

FRACTURES AND TRAUMATIC SURGERY— Two
Weeks’ Intensive Course starting September 22nd.
Informal Course every week.

GYNECOLOGY — Two Weeks’ Intensive Course start-
ing October 20th. Twenty-hour Personal Course in
Vaginal Approach to Pelvic Surgery starting No-
vember 3rd. Clinical and Diagnostic Courses every
week.

OBSTETRICS — Two Weeks’ Intensive Course starting
October 6th. Informal Course every week.

OTOLARYNGOLOGY — Clinical and Special Courses
starting every week.

OPHTHALMOLOGY — Two Weeks’ Intensive Course
starting September 22nd. Five Weeks’ Course in
Refraction Methods starting October 13th. Informal
Course every week.

ROENTGENOLOGY — Courses in X-ray Interpretation,
Fluoroscopy, Deep X-ray Therapy every week.

General, Intensive and Special Courses in
All Branches of Medicine, Surgery and
the Specialties.

TEACHING FACULTY — ATTENDING
STAFF OF COOK COUNTY HOSPITAL

Address:

Registrar, 427 South Honore St„ Chicago, Illinois

Dependable Laboratory

WHEN nothing less than a high degree of
accuracy in a clinical test or a chemical
analysis will serve your purpose, you can
send us your specimens with confidence.
Pleasant, well-equipped examining rooms
await your patients. In either the analytical
or the clinical department of our labora-
tory, your tests will be handled with the
thoroughness and exactitude which is our
undeviating routine. . . Fees are moderate.

Urine Analysis
Blood Chemistry
Hematology
Special Tests
Basal Metabolism
Serology

Directors: Joseph A. \

Parasitology

Mycology

Phenol Coefficients

Bacteriology

Poisons

Court Testimony

[ and Dorothy E. Wolf

Sand f^ot 7gg Jllii

CENTRAL LABORATORIES

Clinical and Chemical Research
312 David Whitney Bldg. * Detroit, Michigan
1030. (Res.) Davison 1220

754

Jour. :\I.S.M.S. j

THE DOCTOR’S LIBRARY

THE DOCTOR’S LIBRARY

Acknowledgment of^ all books received will he made in this
column and this will be deemed by ns as a full compensation
of those sending them. A selection will be made for review,
as expedient.

A PRIMER FOR DIABETIC PATIENTS. An Outline of
Treatment for Diabetes with Diet, Insulin and Protamine-
Zinc Insulin Including Directions and Charts for the Use of
Physicians in Planning Diet Prescriptions. By Russell M.
Wilder, M.D., Ph.D., F.A.C.P; Professor and Chief of the
Department of Medicine of the Mayo Foundation, University
of Minnesota ; Head of Section on Metabolism Therapy,
Division of Medicine, the Mayo Clinic. Seventh edition, .
reset. Philadelphia and London : W. B. Saunders Company,
1941. Price: $1.75.

Russell M. Wilder, the Head of the Section on
^letabolism Therapy at Mayo Clinic, has presented the
seventh edition of this primer originally published in
1921. As he states, this new edition is “required to
describe an improvement in the procedure of administer-
ing protamine-zinc insulin.” His rather liberal diets and
the use of both protamine-zinc and regular insulin in
the one syringe have made the care of these patients
more effective and simpler. The major part of the
book consists of the directions furnished to the patient
who visits the service of Doctor Wilder.

M S M S

INFANTILE PARALYSIS. Anterior Poliomyelitis. By
Philip Lewin, M.D., F.A.C.S. ; Associate Professor of
Bone and Joint Surgery, Northwestern University Medical
School; Professor of Orthopedic Surgery, Cook County Gradu-
ate School of Medicine; Attending Orthopedic Surgeon, Cook
County and Michael Reese Hospitals; Consulting Orthopedic
Surgeon, Municipal Contagious Disease Hospital, Chicago. Il-
lustrated by Harold Laufman, M.D. Philadelphia and London:
W. B. Saunders Company, 1941. Price: $6.00.

The author has written this book especially for the
family physician who usually sees the patient first and
who may be somewhat confused by the numerous
reports and articles which have appeared on this sub-
ject. The major part of the book, of course, deals
with the physical therapeutics and surgical procedures
necessarx’ to restore function to the paralytic patient.-
It is profusely illustrated and complete though compact.

M S M S

CLINICAL AND EXPERIMENTAL INVESTIGATIONS
ON THE GENITAL FUNCTIONS AND THEIR HOR-
MONAL REGULATION. By Bernard Zondek. Baltimore:
The Williams & Wilkins Company, 1941. Price: $4.50.

This monograph presents a continuation of the previ-
ous research work done by Zondek which was published
in German in 1931 and 1935 entitled, “The Hormones
of the Ovary and the Anterior Pituitary Lobes.”
While like most reports of research work and clinical
experimentation this book is not very readable, to the
physician who is interested in sex hormones the material
is markedly informative and for this group this book
is recommended.

MSMS

COLLECTED PAPERS OF THE MAYO CLINIC AND
THE MAYO FOUNDATION. Edited by Richard M.
Hewitt, B.A., M.A., M.D. ; Harry L. Day, Ph.B., M.D. ;
James R. Eckman, A.B. ; A. B. Nevling, M.D. ; John R.
Miner, B.A., Sc.D.; and M. Katharine Smith, B.A. Volume
XXXII — 1940. Philadelphia and London: W. B. Saunders
Company, 1941. Price: $11.50.

This is the 1940 edition in which the material, which
is of particular interest to the general practitioner, the
diagnostician and the general surgeon, is assembled
from the writings of the staff of the Clinic and Found-
ation. Here are seventy-three complete reprints, ninety-
one abridged papers and one hundred five abstracts.
The general quality of the material cannot be questioned
and it is voluminous. The section on military medi-
cine is of particular current interest. This volume is
recommended as an encyclopedic review of the litera-
ture of 1940. The typography is excellent and it is
well illustrated.

(Continued on page 757)

September, 1941

The Modern Physician’s
Office Contains

HANOVIA

EI^UIPMEIKT

SUPER "S" ALPINE SUN LAMP

Built strictly in accordance with Hanovia specifications.
Ideal for the professional office from every stcindpoint:
efficiency, effectiveness, economy, ease of operation.

The Super “S” Alpine Sun Lamp is a high pressure,
high intensity, quartz mercury arc lamp. Starts instantly
at the snap of the switch, tilting not necessary. It has
ten stages of intensity regulation by unique control.

Don’t fail to see our latest development, the

HANOVIA AERO KROMAYER

with new revolutionary features. Higher intensity, self-
lighting burner, no kinking of water tubes, constant
ultra-violet output, same spectrum as alpine lamp, more
concentrated light source, burner operates in every posi-
tion, automatic, full intensity indicator, more ultra-
violet through applicators. No water stoppage . . .
No overheating ... No necessity for cleaning of water
system. Burner housing COOLED BY AIR instead of
water, using new principle of aero-dynamics.

See These Models Demonstrated
at the Convention, Booth C-17

HANOVIA

Chemical and MIg. Co.

5013 Woodward Ave. Detroit

755

DeNIKE
SANITARIUM, Inc.

Established 1893

EXCLUSIVELY for the TREATMENT
OF

ACUTE and CHRONIC
ALCOHOLISM

626 E. GRAND BLVD. DETROIT

Telephones:

Plaza 1777-1778 and Cadillac 2670

A. JAMES DeNIKE, M.D.

Medical Superintendent

POtSSIOHAlPllOrtCIIOM

INCE 1899
PECIALIZED
E R V I C E

A DOCTOR SAYS:

“This has been my first experience
in ten years af licensed practice but
it has been worth all the premiums I
have paid to be able to go ahead with
my work and let your Company do the
worrying.”

<0Si£3

OF

LABORATORY APPARATUS

Coors Porcelain
Pyrex Glassware
R. & B. Calibrated Ware
Chemical Thermometers
Hydrometers
Sphygmomanometers

J. J. Baker & Co., C. P. Chemicals
Stains and Reagents
Standard Solutions

• BIOLOGICALS*

Serums

Antitoxins

Bacterins

Vaccines

Media

Pollens

We are completely equipped and solicit
your inquiry for these lines as well as for
Pharmaceuticals, Chemicals and Supplies,
Surgical Instruments and Dressings.

■7Ue RUPP & BOWMAN CO.

319 SUPERIOR ST., TOLEDO, OHIO

Convenient
and economical

The effectiveness of Mercurochrome has been
demonstrated by twenty years’ extensive clinical use.

For the convenience of physicians Mercurochrome
is supplied in four forms — Aqueous Solution for
the treatment of wounds. Surgical Solution for
preoperative skin disinfection. Tablets and Powder
from which solutions of any desired concentration
may readily be prepared.

{dibrom-oxymercuri-fluorescein-sodium)

is economical because solutions may be dispensed
at low cost. Stock solutions keep indefinitely.

Mercurochrome is accepted by the
Council on Pharmacy and Chemistry of
the American Medical Association.

MEDICAL

ASSN.

Literature furnished on request

HYNSON, WESTCOTT & DUNNING, INC.

BALTIMORE, MARYLAND

756

lorR. M.S.M.S.

I

THE DOCTOR’S LIBRARY

1 START TODAY. Your Guide to Physical Fitness. By C.
i Ward Crampton, M.D., Major, Medical Reserve Corps,

] United States Army, Formerly Director of the Department of
■ Physical Education and Hygiene, New York Board of
i Education ; Organizer and Director Health Service Clinic
and Assistant Professor of Medicine, Post Graduate Med-
i ical School and Hospital; etc. New York: A. S. Barnes
and Company, 1941. Price: $1.75.

I The author was formerly Director of the Department
j of Physical Education and Hygiene of the New York
i Board of Education. He begins with a discussion of
f what constitutes physical fitness and of what a medical
j examination should consist. In the body of this book he
! relates in an interesting manner the method and purpose
] of seven exercises which he feels would keep the
? average citizen from “going soft.” The exercises are
[ simple, easy, and well-planned. It would be difficult for
f any physician to read through this book and not feel
urged to adopt this system of exercise for his own.
This book is recommended for the physician’s private
I and professional use.

|! MSMS

i INFANTILE PARALYSIS. A Symposium Delivered at
j Vanderbilt University, April, 1941. New York: The National
( Foundation for Infantile Paralysis, Inc., 1941.

! The six lectures delivered at Vanderbilt University in
I April, 1941 under the auspices of the National Founda-
I tion for Infantile Paralysis are presented for the edifi-
cation of all interested in this disease. The “History of
Poliomyelitis” which was delivered by Paul Clark of
Wisconsin is most interesting and instructive. Frank
R. Ober’s lecture on the “Treatment and Rehabilitation
of the Poliomyelitis Patient” is practical and should be
of distinct help to the practitioner who has in his hands
i the care of these patients. The material is briefly put
! and practical.

; MSMS

* X-RAY THERAPY OF CHRONIC ARTHRITIS (Including
the X-ray Diagnosis of the Disease). Preliminary report
based on 100 patients treated at Quincy, Illinois. By Karl
I Goldhamer, M.D. ; Associate Roentgenologist, St. Mary’s
i Hospital and Quincy X-ray and Radium Laboratories ;

I Formerly Roentgenologist, University of Vienna; Honorary
I Member, Mississippi Valley Medical Society ; etc. With
: a Foreword by Harold Swanberg, B.S., M.D., F.A.C.P. ;

! Editor, Mississippi Valley Medical Journal and the Radiologic
Review; Roentgenologist, St. Mary’s Hospital and Blessing
Hospital; Director, Quincy X-ray and Radium Laboratories;
Past President, Illinois Radiological Society, etc. With 24
original illustrations by the author, two roentgenograms, and
four tables. Quincy, 111. : Radiologic Review Publishing

Company, 1941. Price: $2.00.

Goldhamer, Chief of the Roentgen Laboratory of
the First Anatomical Institute of the University of
Vienna, became enthusiastic about the possibilities of
x-ray therapy of chronic arthritis. He calls attention to
the fact that there are probably seven million sufferers
! from arthritis in the United States and the excellent
' results which he has obtained by roentgen therapy, in a
i series of one hundred, led him to suggest to the practi-
I tioner the advisability of giving the arthritis patient the
benefit of this treatment. Over half of the patients who
had hypertrophic arthritis were markedly improved or
i symptom-free after treatment and the same was true
of hypertrophic spondylitis. Atrophic arthritis and
atrophic spondylitis showed about the same results.
The results of all cases showed almost sixty per cent
markedly improved or free from symptoms. The
technic and course of treatment is described in this
monograph.

MSMS

PLAY FOR CONVALESCENT CHILDREN. In Hospitals
and at I^me. By Anne Marie Smith, Staff Instructor,
Leaders Training School, Community Recreation Service
Chicago, Illinois. New York: A. S. Barnes & Company’

1941. Price: $1.60.

In the present day program of highly organized
recreation this book should play a definite part. The
activities outlined in this volume would undoubtedly
serve the purpose of making more pleasant the child’s
stay in the hospital.

1 September, 1941

Physicians Heart
Laboratory

523 Professional Building
10 Peterboro Street
Detroit, Michigan

Laboratory Telephones: TEmple 1-5580

Columbia 5580

I A laboratory providing the following
services exclusively to physicians for their
patients:

ELECTROCARDIOGRAM
BASAL METABOLISM
X-RAY of HEART
KYMOGRAPH X-RAY of HEART
VITAL CAPACITY
DIRECT VENOUS PRESSURE

Laboratory Hours: 9 A.M. to 5 P.M.

Interpretative opinions and records avail-
able only to referring physicians.

7.S7

86c out of each $1.00 gross income
used for members benefit

PHYSiaANS CASUALTY ASSOCIATION
PHYSiaANS HEALTH ASSOCIATION

Hospital, Accident, Sickness

INSURANCE

For ethical practitioners exclusively

(56,000 Policies in Force)

LIBERAL HOSPITAL EXPENSE
COVERAGE

$5,000.00 ACCIDENTAL DEATH

$25.00 weekly indemnity, accident and sickness

$10,000.00 ACCIDENTAL DEATH
$50.00 weekly indemnity, accident and sickness

$15,000.00 ACCIDENTAL DEATH

$75.00 weekly indemnity, accident and sickness

For

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per yeai

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per yea:

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per yc

For

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per ye

39 years under the same management

$2,000,000.00 INVESTED ASSETS
$10,000,000.00 PAID FOR CLAIMS

$200,000 deposited with State of Nebraska for pro-
tection of our members.

Disability need not be incurred in line of duty — benefits
from the beginning day of disability.

Send for applications, Doctor, to

400 First National Bank Building Omaha, Nebraska

Physicians' Service Laboratory

608 Kales Bldg. — '
Northwest comer of
Detroit, Michigan

Kahn and Kline Test
Blood Count

Complete Blood Chemistry
Tissue Examination
Allergy Tests
Basal Metabolic Rate
Autogenous Vaccines

^8 W. Adams Ave.

Grand Circus Park

CAdillac 7940

Complete Urine Examina-
tion

Ascheim-Zonde

(Pregnancy)

Smear Examination
Darkfield Examination

All types of mailing containers supplied.
Reports by mail, phone and telegraph.

Write for further information and prices.

CLASSIFIED ADVERTISING

TEN-BED, BRICK VENEER HOSPITAL and good
general practice to sell. Excellent prospect for a
doctor with moderate capital who likes small town
life and out door activities. Full information can
be obtained by writing to the Executive Office,
Michigan State Medical Society, 2020 Olds Tower,
Lansing, Michigan — Box 19.

MSMS

LANSING, MICHIGAN LOCATION

A strictly modern, high class doctors’ building in a
100 per cent doctors’ location.

Land of sufficient size to furnish parking for patients.
Brick building, 48 feet by 32 feet, built in 1929. First
floor now laid out for ear, eye, nose and throat special-
ists. Second floor has 7 fine rooms, a complete bath
and 2 extra toilet and lavatory rooms. Reasonable
price, easy terms. Present owner retiring from practice.
For full information, write C. C. Ludwig, 506 Wilson
Building, Lansing, Michigan.

MSMS

NEWS NOTE

Louis J. Gariepy, M.D., Detroit, was honored at an
Indian Fete held at Harbor Springs July 27 by the
Ottawa Indians. Doctor Gariepy was given the Indian
name of “Say-ge-mah” which means “Man of Medi-
cine” in appreciation of his assistance to the Holy
Childhood School for Indian children at Harbor
Springs.

The Mary E. Pogue School

For Exceptional Ckildren

DOCTORS: You may continue to super-
vise the treatment and care of children
you place in our school. Catalogue on
request.

WHEATON, ILLINOIS

85 Geneva Road Telephone Wheaton 66

THE MAPLES

A Private Sanitarium for the Treatment of Alcoholism

Registered by the A.M.A.

R.F.D. 3, LIMA, OHIO
Phone: High 6447

Located ZYz Miles East of Gomer on
U. S. 30 N.

F. P. Dirlam A. H. Nihizer, M.D.

Superintendent Medical Director

PRESCRIBE OR DISPENSE ZEMMER

Pharmaceuticals, Tablets, Lozenges, Ampules, Capsules, Ointments, etc.
Guaranteed reliable potency. Our products are laboratory controlled.
Write for general price list.

THE ZEMMER COMPANY MIN 9-41

Chemists to the Medical Profession Oakland Station Pittsburgh, Pa.

758

JoL'R. M.S.M.S.

ENZYMOL

A Physiological Surgical Solvent

Prepared Directly From the Fresh Gastric Mucous Membrane

ENZYMOL proves of specicd service in the treatment of pus cases.

ENZYMOL resolves necrotic tissue, exerts a reparative action, dissipates foul odors;
a physiological, enzymic surface action. It does not invade healthy tissue; does not
damage the skin. It is made ready for use, simply by the addition of water.

These ore some notes of clinical application during many years:

Abscess cavities
Antrum operation
Sinus cases
Comeal ulcer

Carbuncle
Rectal fistula
Diabetic gangrene
After removal of tonsils

After tooth extraction
Cleansing mastoid
Middle ear
Cervicitis

Originated and Made by

Fairchild Bros. & Foster

Xew York, IV. Y.

Descriptive Literature Gladly Sent on Request.

KEEP THEM THAT WAY

Now that your patients have gone back to work,
school and the household, stocked up with the
benefits of the summer sun, it is a simple matter
to keep them protected against winter's ultraviolet
deficit by regular irradiation with a

BURDICK QA-450 QUARTZ MERCURY
ULTRAVIOLET LAMP

With this powerful professional lamp, the period of
irradiation is short, and you can give every patient
an opportunity to continue irradiation throughout
the dark winter months.

Ultraviolet is particularly indicated in pregnancy,
lactation, convalescence, infancy, childhood and
debilitating diseases.

THE G. A. INGRAM COMPANY

4444 Woodward Ave. Detroit, Michigan

The G. A. INGRAM CO„ 4444 Woodward Ave., Detroit. Michigan
Please send me complete information on Burdick Ultraviolet equipment.

Dr

Address

City State

iOcTOBER, 1941 767

Say you saw it in the Journal of the Michigan State Medical Society

MICHIGAN MEDICAL SERVICE

i

A report of seventeen months of operation of
Michigan Medical Service was presented at the
Second Annual Meeting of the members of
Michigan Medical Service in Grand Rapids on
September 17. This report contained many items
of real interest to doctors who have made pos-
sible the inauguration of the professionally con-
trolled nonprofit medical service program.

Enrollment. — The total enrollment as of Au-
gust 31 was 193,176 persons, which represents
the cooperation of 501 groups. The steady in-
crease in enrollment is an indication of the favor-
able reception given by the public to the doctors’
own medical service program.

Services to Subscribers. — During the seventeen
months, services were provided for 28,815 pa-
tients, representing an amount of over $650,000
of medical expenses met through the prepayment
program rather than by the individual patients.

A tremendous amount of valuable data relative
to incidence of illness, frequency of medical and
surgical procedures, and costs of medical care
has been accumulated. These data, based
on more than 130,000 years of exposure (time
during which subscribers were entitled to serv-
ices) is far greater than the information on
which the reports of the Committee on the Costs
of Medical Care (costing in excess of $1,000,000)
were based !

Payment to Doctors. — For thirteen consecutive
months, the full Schedule of Benefits was paid
for all services rendered. A combination of an
increased volume of services and late reporting
on the part of the doctors made it necessary, be-
ginning in April, to pay on a prorated basis of
80 per cent of the previous level of payments,
pending a determination of the total cost of serv-
ices for the particular month compared with the
income from subscribers. The payment of the
amount reduced will be dependent on funds
available for the particular month, after determi-
nation of the cost of services can be made (when
all late reports are received) and on those sur-
pluses which may be accumulated during later
months.

MICHIGAN MEDICAL SERVICE REGISTRATION

(As of September 10, 1941) •

100 Per Cent \

Manistee ^ i

Mason j

Mecosta-Osceola-Lake
Menominee

1

90 to 99 Per Cent

Bay-Arenac-Iosco

Calhoun

Gogebic

Grand Traverse-Leelanau-Benzie
Marquette-Alger J

Oceana
St. Joseph

80 to 89 Per Cent

Allegan

Barry

Branch

Chippewa-Mackinac

Delta-Schoolcraft

Dickinson-Iron

Eaton

Gratiot-Isabella-Clare

Hillsdale

Houghton-Baraga-Keweenaw

Huron

Ingham

lonia-Montcalm

Kalamazoo

Kent

Lapeer

Lenawee

Livingston

Midland

Muskegon

Newaygo

Northern Michigan

Ontonagon j

Ottawa 1

Saginaw |

Tuscola j

Wexford-Missaukee |

75 to 79 Per Cent j

Jackson ]

Macomb j

Monroe i

North Central Counties ’>

Oakland |

W ayne

There is an erroneous impression that the
medical service program will mean a financial
loss to the doctor when comparison is made of
the benefits paid in one particular case with the
probable charge that might have been made.
What has been overlooked is the important fact
that the benefit paid under the medical service
program for a series of cases means total re-

768

Jour. M.S.M.S.

He’s os Easy to Reach
os Your Telephone

* G“E s direct representative who reQuiariy
makes the rounds of physicians and hospitals in
. ^yP^OocaUiy, and responds Jo theit^ emergency
, . calls for expert technical service or advice on the
operation and maintenance of ' x-ray and? other
>:^electf6-medical'devlces;''"^-^'%-"^;:'^^^M^%^^f’''

He is neither an agent or distributor for GrE dp
paratus, but is a permanent employee on
payroll, and works under thS jurisdictiS (ol
nearby G-E Branch.

What does this mean to'users of G-;E equipment?

That a specially tralned;field-'^rpaniz<^?^
tion, directly responsible to headquarters^ i/pqr^^
company policies'''estqblis In' fthe^

and reh^ldringlti caHber d

maintenance service essential to the consistently i
satisfactory performance of electo-medical ap- I

I®

“:|p

,-|Tw€nty^ y^ars^ of d^rect^ p-ijrepresentahon:^
conclusively proved^ that this' plan '^ppidys

Jostify^every\dpllar"_;t^^
vest In G-E equipment.

■■■ “■ ' ‘s

; ^ The ;G. E. meij^whd are serving these mutual ih-
^ f^ests in your locality are listed herewith. We
vis1hcerel)jbelieve^t^^ you will find them q reli

able source of helpful s — * ^ ^ ^ ^

■

GENERAL ® ELECTRIC

you saw it in the Journal of the Michigan State Medical Society

769

MICHIGAN MEDICAL SERVICE

muneration equivalent to or greater than that
previously received. This is particularly true
when it is considered that there will be no unre-
munerated services either because of bad collec-
tions or the patient’s lack of funds. While the
monetary advantages can be shown, of foremost
importance is the real professional contribution
of assisting subscribers to obtain services for
medical conditions that have been of long stand-
ing.

Financial Experience. — The financial records
of Michigan Medical Service must necessarily be
tentative until proper accounting can be made for
outstanding, incomplete, and unreported services.
A liberal allowance of $161,202.27 has been made
as a measure of the probable cost of such serv-
ices. Whether this fund will be exhausted when
all services are reported is problematic. Con-
siderable improvement of the financial situation
is expected on the basis of a decrease in service
costs because of (1) a seasoning of the groups
enrolled, since an analysis of groups shows that
during the first five months there is an excess of
service costs over income, but that after a period
of twelve months’ enrollment the income is more
than sufficient to provide for the costs of services ;
(2) the more favorable period of the year, since
it is well established that the period from Sep-
tember to January shows less surgical care than
the balance of the year; (3) decrease in the per-
centage of administration expenses because of
the large volume of enrollment. The relatively
low administration expense of 20 per cent has
been reduced to between 12 and 13 per cent dur-
ing the months of June and July because of the
large enrollment.

Registration of Doctors. — It is particularly
noteworthy that the number of doctors registered
with Michigan Medical Service has increased
month by month. Likewise, but few doctors
have resigned because of misunderstanding. A
total of 3,559 doctors were registered as of
August 31. ; 75 applications received were

withdrawn for the following reasons ; Death,
38; moved out of the state, 9; pending county
medical society action, 7; amount of fees, 11;
arrangements for specialists’ fees, 4 ; and pro ra-
tion, 6. The present number of doctors partici-

pating is at least 80 per cent of the total possible
number of practicing physicians.

Organization. — The prime consideration of the
administrative organization of Michigan Medical
Service has been economy in order that the fund
collected from subscribers might be utilized fully
for medical and surgical services. Michigan
Medical Service has reported their lowest admin-
istrative cost for any comparable program. The
accomplishment of this economy has been possible
through the loyalty and extra long hours of
work on the part of the office employes whose
salaries are minimal. Likewise, the unselfish
services of the members of the several commit-
tees have been a large factor in keeping ad-
ministrative costs down. To some extent the
necessity for economy has hampered efficiency,
but the office procedures are now well organized,
with many functions transferred to International
Business Machines, which greatly facilitate
the prompt handling of reports from doctors and
the remitting of payments.

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(In Affiliation with Cook County Hospital)

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SURGERY — Two Weeks’ Intensive Course in Surgical
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MEDICINE^ — Two Weeks’ Intensive Course in Internal
Medicine and Two Weeks’ Course in Gastro-Enterology
will be offered twice during the year 1942, dates to
be announced. One Month Course in Electrocardiog-
raphy and Heart Disease every month, except De-
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FRACTURES & TRAUMATIC SURGERY— Two

Weeks’ Intensive Course will be offered four times
during the year 1942, dates to be announced. Informal
Course available every week.

GYNECOLOGY — Two Weeks’ Intensive Course will be
offered four times during the year 1942, dates to_ be
announced. Twenty Hour Personal Course in Vaginal
Approach to Pelvic Surgery November 3rd. Clinical
and Diagnostic Courses every week.

OBSTETRICS — Two Weeks’ Intensive Course will be
offered ttvice during the year 1942, dates to be an-
nounced. Informal Course every week.

OTOLARYNGOLOGY — Two Weeks’ Intensive Course
will be offered twice during the year 1942, dates to be
announced. Clinical and Special Courses starting
every week.

OPHTHALMOLOGY — Two Weeks’ Intensive Course
will be offered twice during the year 1942, dates to be
announced. Informal Course every week.

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Address: Registrar, 427 S. Hotiore St., Chicago, 111.

770

Jour. M.S.M.S.

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771

October, 1941

Say you saw it in the Journal of the Michigan State Medical Society

X- HALF A CENTURY AGO X-

FOUR MONTHS' WORK IN LAPAROTOMY*

I. H. CARSTENS. M.D,

Detroit, Michigan

(You will understand, Mr. Chairman, why I made the
emphatic remarks I did, when I say to you it was
simply to take the sharp edge off, which will come after
I read this paper. I have no doubt Dr. Green will give
me particular Hail Columbia; but there were no cases
that we operated upon for the purpose of making wom-
en sterile. I do not believe that there is a member of
the regular medical profession who operates in any
such cases.)

Understanding by laparotomy any operation requir-
ing the opening of the peritoneal cavity, I thought that
the report of a few cases might be interesting to this
Section, especially as it includes different operations
of this kind. The reports of the following cases I have
made as brief as possible, perhaps too much so, but
I desired to keep within the twenty-minute limit.

Case 1. — Mrs. K., aged thirty-three, sterile, sent to
me by Dr. Root, of Monroe. She imagined, or rather
hoped, she was pregnant, but Dr. Root had properly
diagnosed a large multilocular cyst. January 8, I oper-
ated at her home in Monroe, assisted by Drs. Root,
West, Valade, Gregory, and Baur. The fluid was
very thick, some of the cyst wall very thin and rup-
tured, some adhesion to intestines ; right ovary, also
cystic, removed. Abdomen, flushed with sterilized wa-
ter and closed. Recovery rapid, no rise of temperature
above 100°.

Case 2. — Mrs. M.F.W., aged twenty-six, no children,
but one miscarriage three years before ; since ailing ;
has been treated by douches and applications to uterus,
also wore pessary. Examination revealed an enlarged
adherent ovary in cul-de-sac, right ovary also large,
tubes distended, and everything in pelvis very painful ;
has had no connection for one year, on account of
pain. She has also had a slight attack of peritonitis,
so that I made the diagnosis of salpingitis, probably
of gonorrheal origin. I sent her to Harper Hospital,
and operated January 15. Both tubes contained about
one-half ounce pus each, ovaries adherent to uterus,
bladder, and rectum. All removed and abdomen
flushed. A large glass draining tube down to cul-de-
sac was left in lower angle of wound. Recovery quick,
no rise of temperature. Glass tube removed on the
second day, and rubber tube inserted for two days
more. Two weeks after, wound perfectly closed, pa-
tient feeling splendid, and all pelvic pain gone. She
was sent home on the 16th day.

Cctse 3. — Miss C., aged thirty-three, had been oper-
ated upon for salpingitis two years ago in Canada.
During November was taken with a scaly skin disease
and 'went to Harper Hospital under the care of Dr.
Carrier. She had a sudden elevation of temperature, up
to 109° the latter part of the month. This was re-
peated every few weeks, the temperature going up to
110° at times, and in a day or two would go down to

*Presented at the twenty-sixth annual meeting of the Michigan
State Medical Society, Saginaw, June, 1891.

about normal. About January 1 the temperature
went up and stayed up from 106° to 110°, with severe
abdominal pain and symptoms of peritonitis. The
question of septicemia or central nervous lesion came
up. Many physicians saw her, some inclined to ex-
ploratory laparotomy, others thought it would be of
no avail. The patient was clamoring for a laparotomy,
and after consultation, an exploratory laparotomy was
made January 17. Absolutely nothing was found. The
temperature dropped to normal, and the wound healed
without a bad symptom. January 27, she was appar-
ently well and going around the halls. February 4,
temperature up to 109.9° for a short time. What was
it? Hysteria? I give it up.

Case 4. — Mrs. Hess, aged thirty-nine, no children. Has
been sick with high fever and constant vomiting for
three days ; complains only of pain in the abdomen. I
suspected intestinal obstruction, but could not find any;
accidentally my finger came below Poupart’s ligament,
and there I found it — femoral hernia. I sent her to
Harper Hospital and operated February 4, in the usual
manner, except that a radical operation was made by
excision of the sac and uniting the pillars with silk.
The wound was closed by the buried animal suture.
Union perfect, and patient discharged on the four-
teenth day. Today she seems perfectly cured of her
hernia.

Case 5. — Mrs. P., aged thirty, mother of two chil-
dren. For three months had metrorrhagia, at times
quite profuse. Uterus four inches deep and degen-
eration apparently of mucous membrane. Under chloro-
form was thoroughly curetted and cauterized with
carbolic acid. While under the influence of chloro-
form I found a firm tumor in right pelvis, about two
and one-half inches in diameter; laparotomy decided
upon after recovery from anemia and the other oper-
ation. February 6, at Harper Hospital, operated in the
usual manner ; right tube enlarged and ruptured, part-
ly filled with blood and placental tissue : all removed,
also left tube and both ovaries. A case of extra-uter-
ine pregnancy, recovered rapidly, and was sent home
on the thirteenth day quite well.

Case 6. — Mrs. R., aged forty, mother of five children,
last, five months ago. Sick ever since, abdominal tu-
mor, probably pyosalpinx and pelvic abscess. Operation
at Harper Hospital February 7. Right tube contained
pus ; this and right ovary removed. Left side one solid
mass encircling the rectum ; diagnosis, sarcoma. This
I left severely alone, put in a drainage, and closed the
abdomen. Recovery rapid, and without a bad sjTnptom.
The sarcoma will probably end her life in a few
months.

Case 7. — Mrs. F.B.W., aged twenty-one, married
one and one-half years, no children, backache for
years, worse after menstruation, which is regular, but
profuse ; leucorrhea. Examination revealed enlarged
right ovary and tube in the cul-de-sac, probably a re-
sult of a severe fall five years ago. Operation at Har-

JouR. M.S.M.S.

772

TBESE EMEE, THESE TEM. . .

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Sax you saw it in the Journal of the Michigan State Medical Society

October, 1941

HALF A CENTURY AGO

per Hospital February 10. Both tubes full of pus, and
ovaries enlarged and adherent. All removed ; some ad-
hesion to intestines caused slight trouble ; abdomen
closed ; recovery- uninterrupted, except slight abscess
along the course of one suture. Sent home on the
sixteenth day.

Case 8. — Mrs. L. was sent to Harper Hospital from
Pontiac, aged twenty-five, no children, but one mis-
carriage five months ago ; since ailing ; constant eleva-
tion of temperature to 99.5°. On examination I found
a large fluctuating mass in the pelvis. Operated Feb-
ruary 12. The right tube was full of pus and con-
genitally closed, giving it a club-shaped appearance,
about five inches long and one inch at its thickest end ;
this and ovary removed. The left broad ligament and
surrounding tissues were one large abscess, this was
opened thoroughly; the abdomen flushed repeatedly; a
drainage tube inserted, and the abdomen closed. Re-
covery rapid ; tube allowed to remain for two weeks ;
patient sent home the fourth week perfectly recovered.
A letter lately received states that she has gained 19
pounds. Never felt better in her life, a good result
from an unpromising case.

Case 9. — Mrs. L., aged fifty-eight, two children, 30
years ago. Always quite well. Menopause two years
ago. Never any uterine disease. About three months
ago noticed an odorous discharge from vagina, some-
times streaked with blood. She had a slight laceration.
The history was very suspicious, and I removed a small
part of the raw surface for microscopic examination.
Dr. Duffield pronounced it cancer. This is as early a
case as I ever saw, and vaginal hysterectomy was clear-
ly indicated. February 27, at Grace Hospital, the oper-
ation was performed in the usual manner, using the
clamp forceps for the broad ligaments. She had less
shock than I ever saw in such a case. Temperature
never went above 100.2°. The clamps were removed in
fifty-five hours. No bad symptoms except slight tym-
panitis ever developed. Today, nearly four months
after the operation, she is perfectly well.

Case 10. — Mrs. H., aged twenty-eight, mother of two
children, has been gradually getting more nervous.
Subject to neuralgia, rheumatism, indigestion, consti-
pation, headache, et cetera. A year ago I found a retro-
verted lacerated cervix ; left ovary enlarged. As an
experiment, sewed the cervix without much improve-
ment, nor did pessaries, tampons, douches, help her.
I tried this to satisfy her husband who was a physician.
I then saw that only by removal of the diseased ovaries
and the establishment of the menopouse could a radical
change for the better be brought about. She readily
consented. She was taken to the sanharium. Operated
March 9 in the usual manner. Lack of asepsis was
the cause of a small superficial abscess, which, how-
ever, soon healed. She was discharged on the 16th day,
already wonderfully improved. Today she is quite well;
has not enjoyed such health for years.

Case 11. — Miss E., aged twenty-nine, for years suf-
fered from profuse and painful menstruation every
month ; she was confined to bed for four to ten days.
I found fungosities ; thoroughly curetted, and cauter-
ized mucous membrane of uterus. The next month
she was better, but the second as bad as ever. After
four such operations she and I became discouraged
and she consented to removal of the ovaries. Oper-
ation at Harper Hospital March 31. Plain, simple case ;
recovery rapid. Sent home on the thirteenth day.

Case 12. — Mrs. V., aged thirty, mother of two child-
ren, youngest 7 years ; one miscarriage. For five years
has suffered from painful congestive dysmenorrhea and
menorrhagia, dyspepsia, palpitation, pamful coition, et
cetera. On examination I found a displaced ovary ;

uterus retroflexed. As she was anxious to have more
children, I tried a stem and retroflexion pessary for
some time. Although the uterus was straight and
nearly in its proper position, she did not become preg-
nant, and after a year’s treatment she was worse than
ever and I decided upon a laparotomy. She readily con-
sented and entered Harper Hospital April 2. The oper-
ation was done in the usual manner. The left tube con-
tained pus, ovary enlarged and cystic ; both removed.
The other ovary and tube could not be found, although
I explored the pelvis well. Did she have only one tube
and ovary? As the abdomen was clean, no tube was
used, but it was closed in the usual manner. The shock
was profound and vomiting constant, temperature ran
up to 103° on the second day and then declined to
about 99°. The pulse steadily increased to 120, then to
150, and rose until it could not be counted. The patient
could retain nothing, and finally died of heart failure
on the fifth day. Was this septic poisoning? I do
not think so, as I removed this patient from the table
immediately, and operated on the next case, which made
a splendid recovery.

Case 13. — Mrs. A., aged thirty, menstruated first at
fourteen, very painful ; married at seventeen years ;
only child at twenty-four years of age, severe labor.
Since, painful and profuse menstruation, so as to be
obliged to stay in bed from one to ten days every
month. Ovaries inflamed and cul-de-sac adherent. Op-
eration April 2 at Harper Hospital. Recovery without
a bad symptom ; discharged on the thirteenth day.

Case 14. — Mrs. D., aged twenty-seven, mother of one
child seven and one-half years old ; since ailing, pain-
ful and profuse menstruation ; right ovary enlarged,
left tube filled with fluid. Has been treated for years
with douches, applications, et cetera. I wanted to
watch her for a few days — fatal delay — the left tube
ruptured and so-called pelvic cellulitis developed. By
prompt treatment the acute symptoms disappeared and
she seemed so well that I thought a week or two of
tonic treatment would prepare her for an operation.
Procrastination was nearly the thief of a life ; a sec-
ond rupture occurred, which nearly ended her life. I
lost no time and sent her to Harper Hospital. Operated
April 9. Left tube filled with pus, left ovary contained
an abscess in the center, which ruptured during its re-
moval ; right tube and ovary also diseased and removed.
Abdomen flushed. Drainage tube three days. Recovery
complete. Now rides a bicycle ten miles every day.

Case 15. — Mrs. W., aged forty-six, mother of chil-
dren. Has suffered from uterine disease for years and
been treated ad infinitum. Has been operated upon
for piles. I was called to see her by the kindness of
Dr. Jam'eson. Found a large fluctuating mass in right
iliac fossa, also hard nodular mass like glands in
groin. Patient weak and with an irritable stomach.
We decided on an exploratory laparotomy. I sent her
to the sanitarium. Operation April 10, in the usual
manner. Removed both tubes filled with ous. Also
found large nodular mass in pelvis, but did not try
to remove it, only a small piece for microscopic exam-
ination. Flushed abdomen. I introduced drainage tube,
patient vomited continually, and only partially rallied,
the pulse increased in rapid’ ty until death took place
on the second day. The microscope revealed a spindle-
celled sarcoma.

These operations were not made for a record, but
every case was operated upon which seemed to offer
hope, and every patient was given the benefit of an
operation, if it was indicated. Some of the most hope-
less cases recovered and now enjoy good health. I have
reported every case operated upon during this time, and
have not selected my cases. Since my return from

774

lolTR. M.S.M.S.

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775

Say you saw it in the Journal of the Michigan State Medical Society

1

HALF A CENTURY AGO

Europe, September 1 to January 1, 1891, to wit: four
months, I operated on nine cases with one death (sar-
coma). Add these to the others, would be a total of
24 laparotomies in eight months, with three deaths, or
a fraction over 12 per cent, two deaths being due to
malignant disease and one due to heart failure (or
sepsis).

Discussion

Dr. Carstens (closing) : I think there is nothing more
to be said about this matter. The history of my cases,
every one of them, shows that this very plan of treat-
ment advocated by Dr. Leonard has been pursued for
years and years without any beneficial results ; and I
will lay that down as an absolute rule, that every other
means at our disposal ought to be tried before we de-
cide on a laparotomy. I lay down as another rule this,
that healthy ovaries cannot cause any disease, not even
reflex nervous symptoms ; that you must only operate
on diseased ovaries and diseased tubes. I know also
that once in a while those cases Dr. Leonard speaks
of get well ; I know they do. I have seen cases, but I
never know whether they do or not in bad cases, and
his statistics there show that some of those women
came near dying when they were fooling around with
them. I say, give them the benefit of some other kind
of treatment. The operation itself is not very danger-
ous.

As Dr. Nancrede says, you have to draw the line
between these cases. I think some of these cases of
Dr. Leonard’s have got well, but I know some cases
of Dr. Leonard’s have passed into the hands of those
who use the knife and have cured the patient by
laparotomy. That is the way the question stands with
me. I give them the benefit of every possible plan of
treatment, and I don’t remove any healthy ovaries, no
matter what the disease or symptoms are, unless I am
satisfied there is some real disease. I am not inoculated
with that disease they have over in Germany, to oper-
ate for everything, and I operate only as a last resort.
I think sometimees, as Dr. Nancrede says, we wait too
long, until it is too late before we operate. We never
hear anything about these cases of pus tubes in the
abdomen which die, which are called enteritis, which are
buried and are now six feet beneath the sod — we never
hear anything about those cases, but when we pick
up some poor laparotomy case, where the patient dies,
we are generally jumped on for that.

The question of insanity, melancholia, and so on.
Mr. President, I don’t want to listen to. I can show
you right here, within a stone’s throw of this building,
the first case of that kind ever operated upon here,
twelve years ago. She had fits, she had everything, she
was a physical wreck, and ever since her ovary has
been removed she has been a happy wife and the
mother of two children — step-children of course — and
only a few weeks ago she called on me to thank me
for what I had done. I can show you a half dozen
other women, operated on five or six years ago, who
were at that time physical and mental wrecks, and are
now the very pictures of health. So you don’t always
have this followed by melancholia. We have women
suffering from melancholia who have never had their
ovaries removed. We don’t insure the patient that
she is not going to break her leg or become insane
because we operate on her. It is not assumed, because
of the removal of the ovary, that the woman’s health
is guaranteed in the future, that she shall never have
any other disease, but that woman can get any other
disease' like anybody else. Once in a while they may
pick out a case, here and there, where a woman has
become insane from something else — the ovaries amount
to nothing in that connection. What do the ovaries
amount to when, after a certain period in a woman’s
life, they shrivel up? Where is that ovary then and
the uterus? A mere little speck. Do these women be-

come insane? Don’t they enjoy life after the organs
of reproduction are all destroyed except the vagina?

I admit we have got to draw the line regarding the
cases to be operated upon. We are inclined to be en- I
thusiastic, and one is the extreme that wants to operate, i
and the other is the extreme that doesn’t want to I
operate. Simply because Dr. Leonard admits that he \
can’t operate, he doesn’t want any operations per- |
formed. I get real tired when a man comes along here I
who doesn’t know how to operate, who can’t operate,
who isn’t fit to operate, who has not the nerve or |
spunk to do it, and have him come up here and say 1
these operations are not advisable. But a man that has I
the spunk and pluck, and who has operated for the .
length of time he says Dr. Keith has, who finally looks j
back and says in his conscience these things should not 1
be done, does not have his conscience trouble him with 1
the surgery of today. His conscience troubles him with |
the surgery of the past. He thinks he couldn’t help it ;
he was not an aseptic surgeon at the time; he did all t
the business he could. But today we are practicing ''
aseptic surgery with our various precautions, and it is |
an entirely different thing. I will admit that there are 1
men who finally become old, who in the race of life ]
are being run away with by younger men who are get- |
ting all their business ; and that by and by they do not j
get any more business, and they get sour and they •
think these things ought not to be done. You can quote j
all kinds of cases, all kinds of men, all kinds of ex- J
periences ; but you want to learn this other side of )
the case still. There are some surgeons, like the one '
quoted from Cleveland, who have poor statistics. He i
may be a brilliant operator. I know of brilliant sur-
geons, of brilliant operators ; but I wouldn’t have
them operate on me. I know they are dirty, I know
they have never grasped the principles of aseptic sur-
gery, and never can, and their results are bad.

Everybody loses a case once in a while. A man who
is not an aseptic surgeon, who is not imbued with it,
who has not. got microbes on the brain — we see them
everywhere — that man would not have very good suc-
cess : and if that man comes along and gives me sta-
tistics I would take no stock in them whatever. I want
to know the details of his work. I want, to know
how he operates and works before I will take any
stock in his statistics.

So the point and the sum and substance of my im-
pressions are as I have stated. Two of my deaths w'ere
from sarcoma, and one was probably from sepsis. In
a case of sarcoma it is very doubtful whether we should
operate. Another thing that I desire to speak of is,
that we should have more courage when we have once
opened an abdomen and find it inadvisable to go fur-
ther, and shut it up again.

The point in my paper was simply this : that in these
cases, whatever the disease of the pelvic organs may be,
when every other means of treatment has been tried
in these cases, as a last resort laparotomy should be per-
formed ; and that no healthy ovaries ought to be re-
moved, either for symptoms of a reflex nature or any-
thing similar.

COUNCIL AND COMMITTEE MEETINGS

1. Tuesday, September 16 — Ethics Committee — Grand
Rapids — 12 :30 p.m.

2. Tuesday, September 16 — Publication Committee —
Grand Rapids — 6 p.m.

3. Wednesday, September 17 — Industrial Health Com-
mittee— Grand Rapids — 6 p.m.

4. Thursday, September 18 — Cancer Committee —
Grand Rapids — 12 :45 p.m.

5. Thursday, September 18 — Second Session of The
Council — Grand Rapids — 12 :30 p.m.

6. Thursday, September 25 — Child Welfare Commit-
tee— Jackson— 5 p.m.

7. Wednesday, October 15 — Executive Committee of
The Council — Detroit — 1 p.m.

776

Jour. M.S.M.S.

PATHOLOGY OF THE UPPER RESPIRATORY TRACT

Frontal sinus
with congested
mucous mem-
brane and filled
with mucopu-
rulent material.

Cleared
frontal sinus
with normal
mucous
membrane

Congestion causing closure of
ostium of frontal sinus

CATARRHAL INFLAMMATION OF THE FRONTAL SINUS

The above illustration demonstrates the route of infection to the frontal
sinuses — demonstrates, too, the need for adequate drainage of the area.
To shrink congested nasal mucous membranes quickly — to establish
adequate drainage with more prolonged effect than ephedrine, may we
recommend

NEO-SYHEPHRIN HYDROCHLORIDE

(laevo'alpha-hydroxy'beta-methyl-amino'3 hydroxy ethylbenzene hydrochloride)

DOSAGE FORMS:

SOLUTION— in saline solution (14 02. and 1 oz. bottles)
l%in saline solution (14 oz. and 1 oz. bottles)

14% in Ringer’s Solution with Aromatics (14 oz. and 1 02. bottles)

EMULSION — 14% low surface tension (14 oz. and 1 oz. bottles)

JELLY —14% in collapsible tube with applicator

SOLUTION EMULSION JELLY

FREDERICK STEARHS & COMPAHY, Detroit, Michigan

New York Kansas City San Francisco Windsor, Ontario Sydney, Australia

October, 1941

Say you saiv it hi the Journal of the Michigan State Medical Society

777

MISCELLANEOUS

NEW CONDITIONS DEMAND
NEW TECHNIQUES

By Morris Fishbein, M.D.*

When Mr. Pratt spoke to you about the accom-
plishment of the National Physicians’ Committee,
I know that he did not want you to believe offhand
that this great campaign of Life magazine and all
of these advertisements in the newspapers and all
that has gone on in the gradually changing senti-
ment of the American mind regarding so-called so-
cialized or state medicine is the immediate and di-
rect result of the activities of this one organization.
He would' not want you to believe that, and you
as scientific men could not possibly believe that.

However, he did want to show you something
that was scientific; that was that modern living and
modern social trends demand new types of ma-
chinery to accomplish results. Just as the coming
of new types of microscope, of the electron micro-
scope, new types of physical therapy, new types of
chemotherapy, and other new discoveries in medi-
cine make possible a tremendous advance in the
campaign against disease, so also does the coming
of new machinery for popular education make pos-
sible the dissemination of vast amounts of informa-
tion in a way never previously possible. And it
would be very unfortunate indeed if modern medi-
cine failed to realize that it must be scientific in
its utilization of these new tools of publicity and
information and education of the public. Modern
medicine would be just as backward if it failed to
use those devices as if a physician should say to
himself, “I will not use one of these new drugs
that have been invented.

Medicine advances through the use of new tech-
niques, and enlightenment of the public must also
advance through new techniques.

Now, as our Government has advanced, the minds
of people have been bewildered by a great many
new terms which are a part of the jargon of mod-
ern economics. They have been confused by the
jargon of modern propaganda and so-called educa-
tion. All of the various appeals which are utilized
in various ways to our population are recognized
to be essentially propaganda. Simply, the power that
resides in propaganda is now recognized by every
government in the world. Our own government has
adopted techniques which make it extremely difficult
for any organization which is primarily a scientific
organization to avail itself to the fullest of new
techniques nevertheless which are available not only
to commercial organizations and similar bodies but
available now in greater measure to the Government
itself than to any other single organization either
for profit or without profit in our country.

That is the important point to realize. Our own
government has created a great propaganda agency
for the dissemination of information to the Ameri-
can people regarding the activities of our govern-
ment.

Early in American history, in a period around
1776, our nation made a tremendous social gain.
We established a country with constitutional gov-
ernment, which guaranteed to its citizens certain
fundamental rights. One of these was the right
of free speech. Another was the right of freedom

*The text of an address by Morris Fishbein, M.D., delivered
before one hundred seventy-six distinguished physicians from
thirty-two states assembled for the first national conference of
representatives of the National Physicians’ Committee for the
Extension of Medical Service — Cleveland Hotel, Cleveland, Ohio,
June 5, 1941.

of worship. And a third was the right to freedom
of public assembly.

There are many countries in the world where
an assemblage such as takes place here tonight
would, of course, not be possible. But having free-
dom of public assemblage, and having freedom of
speech, you have in your hands two of the greatest
forces that you could possibly get in order to make
your will known to the people of the United States
and in order to make effective the knowledge you
possess.

Would it not then be an extremely archaic and
obsolete performance for a body of scientific men
to fail to utilize, in order to make their thought
and their will and their knowledge effective, the
very technique which the science of dissemination
of information to the public has brought to us
today?

Now, the best way — and I say this advisedly —
in which American medicine can make its will and
its belief and its opinion and its knowledge regard-
ing these new trends widely known to the vast
majority of the American people is through an
organization such as this. . . .

For that very reason I have personally, and with-
out regard to any position which I may hold in
the Headquarters Office of the American Medical
Association, felt that in the National Physicians'
Committee the American medical profession pos-
sesses an organization potential to accomplish more
for education of the American people regarding the
fundamental standards inherent in the establishment
of a high quality of medical service for the people
of the United States, than it could possess in any
other organization.

There are some who have said, “Why should this
independent organization, coming into the field,
utilize the county societies of the American Med-
ical Association or the state societies or any such
similar bodies in its work?” The answer, of course,
again is the simple scientific answer; that here are
groups of men who assemble regularly, the very
groups that you want to reach, the most effective
groups that you could possibly reach. And why
should it be necessary then to assembly a wholly
new type of machinery in order to carry out a
laudable purpose?'

At the first so-called National Health Conference,
Mr. Michael Davis arose and said, “American medi-
cine travels on a bicycle and social medicine trav-
els in an airplane.” He rather sneered at the w’ay
in which American medicine travels on a bicycle.
That analogy actually should be applied not to
medical service but to the utilization of these new
forms of public education to which I have already
referred.

Again, I would say that at this particular moment
many of the social gains which were agitated in
the five years which have just passed are tem-
porarily in abeyance.

But I would point out to all of you that they
are only in abeyance because, for the immediate
present, other matters are demanding emergency
attention and action.

There exist in the United States many professions
and groups which have for their objective the crea-
tion of a new technique in medical practice which
would put the layman rather than the physician in
charge of setting standards and providing medical
service. So long as these professions and groups
continue to exist and to grow in numbers, just so
long will there have to be continuously in the fore-
front for the protection of medical science, an
organization such as this, which can carry on not
only an effective defense but an effective warfare.

Tour. IM.S.M.S.

778

TKe JOURNAL

of the Michigan State Medical Society

Issued Monthly Under the Direction of the Council

Volume 40

October, 1941

Number 10

The Adjustment of Marital
Problems*

By Lowell S. Selling, M.D., Ph.D., Dr.P.H.,
F.A.C.P.

Detroit, Michigan

Lowell S. Selling, M.D.

A.B., University of Michigan, 1922; A.M.,
in psychology, Columbia University, 1925;
Sc.M., in physiology. New York University,

1925; M.D., University and Bellevue Hospi-
tal Medical College, 1928; Ph.D., Columbia
University, 1930; M.S.P.H., University of

Michigan, 1939;; Dr.P.H., University of Mich-
igan, 1940. Director, Psychopathic Clinic,
Recorder’ s Court; Adjunct Attending ^ Neur“o-
psychiatrist. Harper Hospital; Associate At-
tending N europsychiatrist, Eloise Hospital.
Fellow, American College _ of Physicians,
American Psychiatric Association, American
Association for the Advancement of Science,
American Association of Applied Psychology,
American Association on Mental Deficiency,
American Orthopsychiatric Association, Amer-
ican Public Health Association, British Psy-
chological Society, Royal Medico-Psychologi-
cal Society, Asociasion Medica Argentina —
Sociedad de Medicina Legal y Toxicologia,
Sociedade de Medicina Legal e Criminologia
de Sqo Paulo. Member, Advisory Board of
the Journal of Criminal Law and Criminology,
Advisory Board of the Journal of Criminal
Psychopathology, Michigan State Medical So-
ciety.

■ One of the most deeply entrenched traditions
of medicine is that of “the family doctor.” This
man has been free to move from one social strat-
um to another. He was welcome in all homes as
a guest ; few had any hesitancy about asking his
advice when there was a need, even though there
might have been no money to pay his fee.

The tradition of the family doctor, who drove
his horse through snow banks and blizzards,
rested not only on his ability to alleviate pain
and suffering and his ability to restore to
health the wage earner and the housewife, but
also equally as much on his ability to serve
as a family counselor.

*Presented at the Noon Day Study Club, at the Wayne
County Medical Society Clubrooms, January 14, 1940.

From the Psychopathic Clinic of the Recorder’s Court, De-
troit, Michigan. Series NP, No. 6.

October, 1941

His knowledge of law might not have been as
extensive as that of local attorneys, but his knowl-
edge of human nature frequently helped people
to avoid the courts of law. Sometimes he could
effect a settlement between two individuals who
were both patients ; at other times he could sug-
gest that the Judge or the Prosecutor be lenient
in a deserving case. He rarely counseled divorce,
for from his point of view he felt that it was
unnecessary; that people could be kept together
even though they might have their trials and
tribulations. Occasionally the husband might be
a drunkard who abused his 'wife; and in cases
where there were children to consider, the family
doctor would expend as much effort to aid the
family in its social adjustment, as he would to set
a broken leg or to cure a case of pneumonia.

Family relations institutes are being set up in
various parts of the country by private agencies,
of which the one in Los Angeles headed by Dr.
Popenoef is a classic example. Courts in Phila-
delphia, New York, and Chicago, as well as De-
troit, have clinical facilities for aiding in the
medical and psychiatric adjustment of these
people. Our clinic has seen well over a thousand
Domestic Relations cases, has aided in the ad-
justment of some, has referred others to private
physicians or to public agencies for help. There
are certain premises which must be set up in
dealing with cases involving domestic relations
situations. Some of these will be discussed in
detail.

In the first place, it must be remembered that
the married couple must be considered as two
integrated but individual organisms. Each one
possesses a personality which is built up through
the years, and which is distinctive from the other.
Each personality started with the genesis of their
respective family trees, as the ancestors con-

tcf. Popenoe, P., Modern Marriage, New York, The Mac-
millan Company, 1940, p. 299.

789

MARITAL PROBLEMS— SELLING

tributed to each one of the couple by giving to
him or to her points of strength or weakness
which the early environment, adolescence, ma-
turity, and marital life had modified.

There is no known group of individuals who,
as a group, are not marriageable. For example,
there is no non-marriageable race, or obviously
no non-marriageable limitations on size, for mid-
gets can marry and make a successful adjustment
and so can giants within their own groups. The
color of hair and eyes, and other factors in the
physique (in themselves inherently), mean noth-
ing in causing or solving the problem of marriage.

In dealing with marriage, which we recognize
as a socio-medical problem, the old-fashioned
doctor possessed fewer scientific aids than he did
in his strictly medical practice, which a few gen-
erations ago had none too many resources at
hand. The study of psychiatry was still in its in-
fancy, especially the type or division of psychia-
try not primarily concerned with the diagnosis and
treatment of psychoses, but which was designed
to give assistance to people in the art of getting
along with one another. In spite of his lack of
formal precept, he achieved great success because
his common sense guided him, and his affection
for his patients was limitless.

Today perhaps we have less actual attach-
ment for the patient but more science in our
armamentarium. Every physician sees cases in-
volving domestic conflict in his office, perhaps
daily, depending on his clientele. Sometimes the
case comes to him because there is nowhere else
to turn. Some physicians are faced with do-
mestic adjustment problems because of the na-
ture of their specialties. This is particularly
true of the men in the genito-urinary, gynecologi-
cal, and obstetrical fields, as well as in the fields
of the pediatrician and the psychiatrist. I have
mentioned these specialties in particular, but the
general practitioner would likewise examine and
treat as many cases as the specialist if he were
in a neighborhood where his patients were ac-
customed to come to him with troubles beyond
mere aches and pains. The orthopedist sees cases
of laborers or others who need bone and joint
correction, in order that they may continue to
support their families.

Domestic adjustment offers a problem which
is as deeply integrated with medicine as the prob-
lem of bacterial infection. Much research has
been done in this field. Nevertheless, between

two individuals, body build, color, education,
physical condition, religion, when endowed with
special significance by one of the partners, can |
become primarily responsible for marital conflict. )
A number of studies have been made, prima- ^
rily by sociologists, to show that individuals who ?
come from different racial origin, such as the
mulatto, the Chinese- white cross, Indian-Negro-
even Indian-white cross, have less chance in a
successful marriage than when both are of the
same genesis or when the racial intermarriage is
acceptable to both races, so that the best elements
of both races are brought together, such as Ha-
waiian and Chinese cross. The Irish and German
combination in this country seems to be less suc-
cessful than even Irish-Irish, Scotch-Irish, even '
Irish-English — I say “even” because of the fact
that there are cultural problems of a “traditional
nature” that arise from this last combination.

The treatment of domestic relations problems
lies in three spheres. The first sphere is the pre- •
marital treatment. In other words, the preven-
tion of marital discord by advice and correction
of defects before marriage. This lies in the
field of sex education, education for marriage, as
well as medical care. The universities, the Y.M.
C.A.’s, and churches are doing a great deal along
the first two lines. I feel that this type of work ’
when carried on by laymen must not be encour-
aged to too great an extent, but there is no rea-
son why, in certain spheres of marriage, such
as the economic and purely biological, theoretical
advice by properly trained people cannot be given.
However, it is not the place of this paper to dis- ;
cuss this sphere. Premarital advice is deserv-
ing of extensive treatment and, as a matter of |
fact, all books on marital adjustment contain »
discussions of these matters. •

The other two phases, postmarital and patho-
logical, are of greater importance. The preven- <
tion of marital conflict after marriage is con- !
cerned with correction of the emotional adjust- j
ment or physical ailments which may occur after |
marriage by means of competent advice and help .
in understanding each other, particularly by the
family physician. The third, and the largest,
sphere of domestic relations adjustment lies in
the correction of pathology. This pathology
may be due to false fantasy life or infantile con-
cepts of marriage because each partner was not
being truly himself during the courtship, or even
actual neuroses, and may reveal itself in fights,

Tour. M.S.M.S. -

790

MARITAL PROBLEMS— SELLING

in endless arguments or disagreements between
the members of the marriage.

General Causes of Domestic Difficulty

Physical Disability. — By physical I mean not
only sicknesses and ailments of a general system-
ic nature which preclude the husband working or
the wife taking care of the house, but also those
disorders of the sexual function which prevent
sex satisfaction in marriage.

Some individuals believe that there is a ten-
dency on the part of psychiatrists to over-empha-
size the significance of sexual maladjustment,
but it is certainly true that persons who are
maladjusted sexually are more apt to be irritable,
and in other ways to present special problems
because they are unable to hide their real feel-
ings. A husband says his wife will not receive
him sufficiently, frequently, or with sufficient
show of enjoyment so he in turn rejects his wife
and frequently stays away from home. This be-
havior consequently gives rise to jealousy and
suspicions of various kinds.

From a treatment standpoint it is possible for
the mildly sexually maladjusted individual to be
taught by his physician to make an adjustment.
If there is a vaginal malformation or hyper-
spadias, operative proceedings are possible, but
dyspareunia (a condition which frequently brings
the maladjusted couple to the physician) is more
often on a psychogenic than a somatogenic basis.

The treatment for the physical discord lies
specifically in the hands of the physician. If the
husband is sickly he can be treated through regu-
lar medical means. The wife can be brought
to an understanding of his condition and if the
treatment is successful it will make the husband
a more adequate man both economically and
physically.

If the wife suffers from an ailment, the family,
particularly one which is economically secure,
can, by proper arrangement of domestic service,
learn to compensate for her incompetence until
such time as she can recover enough to take over
her household duties.

Only too often the physician forgets that when
there is a physical incapacity of either of the
partners in a marriage, there are duties and ob-
ligations which must be taken over by the other,
and while the doctor may be treating the man
his wife will need encouragement, sympathy, and

perhaps an understanding explanation so that she
can bear her burden better, and, of course, the
reverse is the case if the wife is ill.

Emotional Integration. — ^The second type of
marital dysfunction that needs aid from the phy-
sician in adjustment is that which frankly may
be called emotional integration. When two
strange people find it necessary to live together
constantly for a matter of eight or nine hours a
day, the similarity of tastes and the identity of
interest is bound to find, on the one hand, rough
spots, and on the other, sensitive areas upon
which the rough spots rub. These can be ad-
justed by each partner carefully working on these
problems and each trying to do things which
each knows will add to the happiness of the
partner. No two people can be expected to be
entirely congenial. Even those who as children
have lived next to each other, and have been
brought up in the same school, whose parents
have moved with the same group, who are mem-
bers of the same religious faith, these come be-
fore the clinician with marital maladjustment re-
quiring some aid.

Often, the physician can encourage each of the
individuals to tell him what particular small
features in the marriage are most annoying.
These can then be tactfully conveyed to the other
partner. Among the complaints that newly mar-
ried men have of their wives’ conduct are very
small things ; such as leaving the cap off the
toothpaste, leaving the tools out of the tool chest,
straightening out the desk so that “I can’t find
a thing that I want to lay my hands on when I
want it.”

Cooking and eating . habits of the two partners
may lead to conflict. When the husband or the
wife has been brought up in restaurants, for
example, he or she is apt to like over-cooked
meat, canned peas, mashed potatoes. The idea
of the highly diversified type of menu to which
the person who has been brought up in a wealthy
home would be habituated is to the restaurant-
raised almost repugnant. Many persons after
marriage discover that they have food fads and
eating habits which have not been corrected by
their parents. They find, in addition, that the
mate has other food fads and eating habits and
the nutritional problem becomes a severe one not
only from a standpoint of nourishment and a
balanced diet but also from the standpoint of

October, 1941

791

MARITAL PROBLEMS— SELLING

enjoying the food. For instance, the husband
may like lettuce and cabbage, and the wife -may
not. The husband may reject starches with the
probable exception of pies — most men like them
— while the wife may prefer pastries to pie, and
would prefer macaroni, potatoes, rice and other
inexpensive staples. The typical case of domes-
tic maladjustment of this type is, of course, the
well-known Jack Spratt family. The physician
who has acquainted himself with diets, prepara-
tion of food, its purchase and service (of great
importance in specialties dealing with metabolism
or gastro-enterology) should be able to give the
wife advice for gradually weaning her husband
over to adjust to the mate’s food habits.

Economic Maladjustment. — A number of cases
where husband and wife conflict over the distri-
bution of the joint wealth and over the husband’s
incapacity to supply the demands of the wife are
numerous, and yet I do not believe that their
number is as great as the uninitiated suppose.
Such conflicts are the most remediable, and yet,
for the physician, present the most difficulty,
because only too many physicians are not able
to handle their own budgets. Problems arise
when spending of money for hobbies, books, or
special leisure activity is curtailed suddenly.
Prior to marriage, plans of specific interest to
the individual are frequently made ; now all lei-
sure activity must be planned to keep the partner
in mind, so that he may share equally or be
included in other activities.

There is, in this country, a rapidly increasing
body of experts who deal with the handling of
the domestic budget. It is surprising to note in
newspaper columns, such as those of Nancy
Brown or Ruth Alden, how scientifically the in-
come in a household can be rearranged. While
the ps}^chiatric advice, which is given only too
often by these newspaper writers, is not usually
very good — more and more we notice newspapers
advising individuals to consult a psychiatrist for
solution of their problems. The difficulty of the
adviser is to reconcile the desires, ambitions and
wishes of either one or both members of the
marriage with the actuality of a fixed income or
an income which, particularly among the labor-
ing class, is not too stable. It is not the place
here to offer arguments for an annual wage, but
I am sure that a very large proportion of our
domestic relations cases occurring among work-

ing people and arising from economic maladjust-
ment could be obviated if some sort of a con-
sistent budget could be planned. However, rea-
sonable goals must be set. The man who is uiak-
ing $1800 a year cannot expect to build a house
in Palmer Woods nor should the business leader
restrict his wife to cotton-print dresses.

Child Guidance. — The fourth group of domes-
tic maladjustments are those which apparently
lie in the field of rearing the offspring, and have
roots deeply imbedded in the unconscious and
do not stem from the obvious surface conflicts.
The field of child guidance is an immense one
and one of many ramifications. There is insuf-
ficient space here to cover all the exigencies that
arise, yet, one or two examples will suffice to
show how a child may be brought to the pedia-
trician or to the general practitioner when the
actual cause of the symptoms lies not in the
child or his mentality but in the attitude of the
parents toward one another or toward the child.

Take for example the annoying habit of bed
wetting. It is not infrequently the case that
when a child is wetting his bed that he is doing
it to attract the attention of the mother. The
child finds that being a bedwetter he gets a scold-
ing every morning or he might even be awak-
ened in the night to get a scolding. Whether
he is getting pleasure or pain from this relation-
ship is not the crucial point but the point is
that he is getting attention which he craves.

The question immediately arises as to why
he demands this attention. Sometimes it is be-
cause the sex adjustment between the parents is
inadequate — the mother rejects the father, and
because the boy looks a bit like his father, or
merely because he is a boy, there is a tendency
to reject him. He runs to her with a little piece
of paper and wants “mummy” to look at it,
she pays no attention and goes along about her
business. She may, if financial circumstances
permit it, go to card parties in order not to have
to take care of the child for an afternoon.

The therapy here primarily lies not with the
child, but in aiding the sexual adjustment of
the parents. A knowledge of the causes of sex
maladjustment is pointed out under the first
cause for marital friction. Deep understanding
on the part of the physician can be gained only
from experience, but he must look for something

792

Jour. M.S.M.S.

MARITAL PROBLEMS— SELLING

more than a palliative means of removing im-
mediate symptoms such as the bedwetting.

Further, as was pointed out by Dr. Gilbert
Rich at the last Central Neuropsychiatric Asso-
ciation meeting, if one can devise an apparatus
to wake the child up before he wets the bed,
this will remove the source of friction and the
mother will tend less to reject the child, and in
diminishing the rejection of the child may be-
come emotionally more secure and more adjusted
to the husband. One can generalize then by
saying that the problem child is the child of
problem parents and the physician should work
on both problems to remedy either.

Another type of marital maladjustment which
arises during child rearing occurs when the child
shows symptoms of being overprotected or
“spoiled.” The mother who has lost another
child, or who herself had an unhappy childhood,
tends to devote too much attention to the child,
particularly if it is the only one. The father,
coming home and finding the youngster diso-
bedient, quarrelsome and noisy (and having no
understanding of the causes of these symptoms)
rejects his wife and considers her incompetent.
She needs emotional adjustment under these cir-
cumstances in the adjustment of her own atti-
tude toward the child so that when this is re-
solved her attitude toward the husband improves
and with an improvement in the child’s behavior
his attitude toward both is helped. In this par-
ticular sphere a lesson to every physician dealing
with children can be brought out, for the physi-
cian should treat not only the physical ailment
of the child but the attitude of the parents while
the child is sick. The doctor must not permit
too much over-indulgence to compensate for the
child’s pains. Since it is a tragic occasion when
a loved child or husband or wife is lost, the
physician cannot shake his head, offer a few
words of sympathy, and walk out the door. He
must turn his attention to the understanding of
the needs of the bereaved one, and suggest, if pos-
sible, some other outlet, some other interest, by
means of which it might be possible to distract
the patient or to prevent a later emotional con-
flict arising from this bereavement.

Neurotic Mechanisms. — The fifth type of cause
of marital dissatisfaction is a deep-seated one.
It is one which almost inevitably calls for the
aid of the psychiatrist. Merely because it calls

October, 1941

for this aid does not preclude intelligent prelim-
inary treatment on the part of the general physi-
cian. This group comprises cases of misidenti-
fication, or neurotic mechanisms arising from the
setting-up in childhood of serious complex ma-
terial. An example of a case such as this is the
patient who is tied to his mother’s apron strings
and who develops what, in brief, is called Oedi-
pus Complex, an emotional over-attachment to
the mother with incestuous ideas, and hatred for
the father. The patient grows up and finds that
to his mind no woman is really good enough for
him for he is latently homosexual. Yet because
of aggressiveness of the woman who is to be
his wife in the future or because society seems to
demand it of him, he marries. When difficulty
develops neither the patient nor his wife can
put their finger on the trouble for the complexes
are deeply hidden. Perhaps the only symptoms
that the man is aware of as he grows up is the
fact that has a tendency to worry, or he has a
tendency to brood, or perhaps a preference to re-
main by himself and to be not companionable.
Such a patient, when he faces the demands of
the marital state, is inadequate, or perhaps he
finds himself to be sexually incompetent, or per-
haps he is only irritated by the fact that he must
feed an extra woman who does not represent his
mother, or in some cases who symbolized his
mother to such an extent that he has actual feel-
ings of guilt when lying next to her.

The foregoing is only one illustration of the
“infantile conflict” type of case and will serve
to reveal the problems and their significance in
marriage for this vast group of complex-ridden
individuals who are neither insane nor diagnos-
ably neurotic. The private physician must learn
to recognize that the patient is not necessarily
telling him causative facts when he speaks of the
things which he dislikes about his wife. A deep
attachment to the mother should offer to the phy-
sician proof that there is some deep-seated con-
flict that needs to be taken care of.

External Circumstances. — The last group of
domestic maladjusted cases are those which are
maladjusted because of external circumstances,
such as the interfering mother-in-law; religious
conflict in which the priest, minister or rabbi
comes to set up in the minds of one or the other
of the partners the idea that he or she should
not be married outside his faith, conflicts because

79J

MARITAL PROBLEMS— SELLING

of educational differences or differences in inter-
est— where the wife wants to go out and dance
night after night because she is still a youngster
and feels that dancing is part of her youth, al-
though she married an older man for the security
that he can give her — or where the background
and experiences of the two partners are widely
different. These latter are more familiar to the
lay person. One cannot enumerate all of the
possibilities in this sphere, even these are avail-
able to treatment by the physician. For example,
the physician can recommend that the family
get away from the offending “in-law.” He can
discuss in a rational manner, with a woman who
has sufficient intelligence, the fact that she is get-
ting other satisfactions which can be substituted
for the recreations which she still thinks she
needs. The inadequate mate who does not like
symphonies, reading, or intellectual recreation,
can often be brought by means of night school or
clubs to a level of understanding where an ad-
justment is possible. But before ascribing the
domestic situation to these external causes one
should be careful to eliminate all the deeper emo-
tional, economic and the conflictual possibilities.

I want to cite briefly one case which has
come to the clinic. “Barbara” is a twenty-
two year old white girl who is Canadian born.
She was married to a man several years older
than herself and she claimed that the husband
was assaultive. He emphasized her irritability.
While her husband drank, he did not drink to a
great extent. He wished companionship which
he was not getting from his morose wife. Care-
ful investigation showed that there was nothing
in the emotional adjustment, in the economic ad-
justment, or in the physical adjustment. The sex-
ual relations were satisfactory. However, the
wife happened to be a Canadian-born person 3nd
the legitimacy of her immigration was in ques-
tion; there was danger of her being deported to
Canada. This problem made her morose so that
she was a pest around the house. The husband
reacted in an unfortunate fashion to this morose-
ness, and not knowing the cause he began to
sta)i^ out. As her maladjustment got worse she
believed that he was being unfaithful. By the
time that we saw both of these people there
seemed to be little hope for the marriage. How-
ever, her immigration problem was settled with
the authorities ; it was found that she was not
in any danger of being deported, and it was only

794

a few months before the family friction cleared
up. I

To summarize, it can be said that the problem :
of adjusting domestic relations cases is a complex
one. The greatest prevention can be done either ,
in the early days of marriage or premaritally.

However, maladjustments of various types can
be treated even after they have gone along for ■
considerable time if the causative factors can be
analyzed and worked out, and if both partners
will be frank and cooperative. The physician
must be sympathetic, and must be willing to look ’
into causes beyond those which would give rise i
to merely physical symptoms. He must be will- )
ing to observe the fields of activity for conflicts j
on the basis of education, religion, recreation, as
well as other fields ; he must be aware that un- I
fortunate friends or relatives can set up a conflict |
and he must know that deep-seated conflicts arise ]
during childhood because of basic infantile neu- ’
roses. This last type, of course, is a very fre-
quently found kind of marital adjustment case
and I would emphasize that only preliminary
work should be done by the physician for the ^
actual cure should be worked out with the psy- ;
chiatrist. |

All in all, each case must be handled as an in-
dividual. There is no reason why, by means of ;
a solution of a marital problem, the physician j
cannot tie to himself a grateful family, in the j
same way that the old-time practitioner used to

CLINIC

Your name? Your age? Where do you live?

Your height? Your weight? Yes, you must give
Your mother’s name. Your father’s name.

Your brother’s name. Your work? Your wage?
Your boss? Your shop? Here put an X
Right at the top. It means you’re poor.

That’s all ; sit down. And wait, you’re poor.

Doctor? No. Sit down, no hurry.

Come? He’ll come sometime, don’t worry'.

Time? It’s eight. Time? It’s nine.

Time? It’s ten. Time? It’s time.

Your name? Your age? Hurt much? Hurt here?
Say ahhh, relax. Lean back, draw near.

Say ahhh, breathe out — And out — and in —

Go home? No, wait. The nurse must have
Some facts. Please state your middle name.

Your mother’s name. Your father’s name.

Your brother’s name

By Sala Weltman, age 12, the first prize poem in the annual
high school poetry contest in New York City. — From West-
Chester Medical Bulletin and Connecticut State Medical Journal.

I

Jour. M.S.M.S.

1

UTERINE FIBROIDS— WILLSON

Uterine Fibroids Complicating
Pregnancy*

J. Robert Willson, M.D.

Ann Arbor, Michigan

J. Robert Willson, M.D.

M.D., University of Michigan Medical
School, 1937. Instructor in Obstetrics and
Gynecology, University of Michigan Medical
School.

■ The management of pregnancy complicated

by fibroids of the uterus generally entails
greater responsibility for the obstetrician than
does the management of the normal patient, espe-
cially when it may be the last or only opportunity
for the individual to have a baby. Since the in-
cidence of complications during pregnancy, labor
and the puerperium is higher in these patients
than in a similar group of normal patients there
is a natural tendency to attribute any abnormality
which may arise to the fibroid. This assumed re-
lationship has occasionally led to hasty and even
needless interference. Accumulated data and ex-
perience have proved that pregnancy complicated
by fibroids should be managed conservatively
unless interference is clearly indicated.

As pointed out by Lynch® there are, In general,
four methods of caring for these patients during
pregnancy :

Hysterectomy during early pregnancy. This
radical procedure is necessary in only a small
percentage of cases and should not be done with-
out first considering other acceptable methods of
treatment. In most instances the patient should
be allowed to carry the pregnancy to term, at
which time abdominal delivery and hysterectomy
may be performed if necessary. In a few cases
of early pregnancy associated with multinodular
tumors the operation may be both justifiable and
necessary.

Therapeutic abortion. Interruption of preg-
nancy certainly does not solve the problem. Be-
cause of the distorted uterine cavity the abortion
may be difficult and furthermore it does nothing
to prevent the recurrence of the same complica-
tion with another pregnancy. If the tumors are
large enough to prevent the pregnancy from be-
ing carried to term Immediate hysterectomy is
probably indicated.

*From the Department of Obstetrics and Gynecology, Uni-
versity of Michigan Medical School.

Myomectomy. The removal of tumors from
the pregnant uterus Is no longer granted wide-
spread acceptance. Myomectomy may be suc-
cessful when there exists a single small tumor,
but with multiple nodules it is likely to result in
interruption of the pregnancy. The increased
vascularity of the hypertrophic uterine muscula-
ture makes perfect closure of the tumor bed
difficult and bleeding from the operative site is
not uncommon.

Mussey and Hardwick® resorted to. myomec-
tomy thirty-two times with twelve abortions,
three premature deliveries and one maternal
death. All of Eisaman’s^ three operations for
the removal of tumors were followed by abortion.
TroelB^ reported 157 myomectomies during preg-
nancy with a fetal mortality of 23.9 per cent and
a maternal mortality of 3.9 per cent.

Carry the patient to term. While a program of
non-interference is not always desirable it seems
to be the most satisfactory method of treatment
for the majority of cases.

Occurrence

In the last 5,271 consecutive deliveries at the
University of Michigan Maternity Hospital
fifty-three were complicated by the presence of
uterine fibroids, an incidence of 1 per cent. The
incidence In this series compares with those re-
ported by Watson^® (1 per cent), Emge® (1.3
per cent) and Pierson^ (0.8 per cent), but is
somewhat higher than Campbelhs^ (0.43 per
cent) and Pinard’s® (0.6 per cent).

Age and Parity. The average age of this
group of patients was 34.5 years; the youngest
was 19 and the oldest 47. The greatest incidence
was between ages 30 and 39 and the lowest
among patients under 20 years of age. Twenty-
one were primipara and 32 multipara. The par-
ity distribution is shown In Table I.

TABLE I. ^DISTRIBUTION OF PARITY

Para 0 21

I 9

II 7

III 6

IV 4

V 2

VI 3

X 1

Effect on Pregnancy

Of our fifty-three pregnancies complicated by
uterine fibroids, eight, or 15 per cent, had tumors

October, 1941

795

UTERINE FIBROIDS— WILLSON

large enough to require hysterectomy in the
early months of pregnancy. The largest of these
extended to the right costal margin at fourteen
weeks and the smallest reached the level of the
umbilicus at the twelfth week of pregnancy. The
average age of this group of patients was 39
years. Four of the patients were primipara and
four multipara.

There was considerable variation in the size
of the tumors in the remaining forty-five patients
but all were palpable on the first examination
and large enough so that it was the opinion of
the examiner that they might interfere with the
pregnancy.

Four, or 8.8 per cent, of the forty-five patients
aborted between two and one-half and six and
one-half months. Three of these had cramps
and irregular intervals of bleeding throughout the
entire duration of their pregnancies. In the
fourth patient termination followed an attempt
at replacement of a retroverted incarcerated
uterus. The incidence of abortion is somewhat
lower than is reported by others. Eisaman^ re-
ported abortion is 12.6 per cent and Campbell in
14.7 per cent. Watson^^ estimates that 15 per
cent to 24 per cent of pregnancies complicated by
fibroids terminate in abortion and Studdiford^^
states that premature termination is three times
more frequent than in normal individuals.

The other common complications occurring
during pregnancy may be attributed to impair-
ment of the blood supply to the enlarging tumors,
which is thought to result in degenerative change.

According to Emge^ there is both an actual
and a relative increase in the size of the tumors
during pregnancy. The actual enlargement is in
a ratio equal to the uterine development and is
due to hypertrophy of the tumor elements, edema
and an increase in the blood supply. As the
uterus enlarges to accommodate the growing fe-
tus the wall becomes thinner and the fibroid nod-
ules become more prominent; this factor plus
the true enlargement of the tumors gives an im-
pression of more rapid growth than actually oc-
curs. Tumors low in the posterior wall of the
uterus may grow to considerable size leading to
their incarceration in the pelvis and, in some in-
stances, to compression of the pelvic soft tissues.

Red degeneration, which usually occurs dur-
ing the second trimester of pregnancy, pre-
sents a fairly typical symptom complex. The
usual clinical picture is that of a sudden onset

of pain localized over a fibroid, with a tem-
perature elevation of one or two degrees and
a moderate leukocytosis. The tumor is tender
to palpation and a definite increase in size may
be noted. As the pregnancy advances the
fibroids outgrow their blood supply eind be-
come relatively avascular; vascularity may be
further compromised by torsion of the tumor
in its bed due to the intermittent uterine con-
tractions during pregnancy. Infiltration of
blood occurs throughout the embarrassed tu-
mor, the resulting hemolysis stains the tissue
the typical color associated with red degen-
eration, which has been compared to that of
raw beef. The affected tumor becomes soft
and enlarged and, when sectioned, bulges out
of its capsule. There occurs tissue necrosis
with loss of cell outline, the microscopic pic-
ture of infarction, but, as pointed out by Po-
lak, there is usually enough normal tissue at
the periphery so the tumor may recover.

The incidence of degenerative changes in
fibroids during pregnancy is relatively high.
Campbell” found necrosis to be present ten
times more frequently in fibroids from pregnant
than from nonpregnant uteri. He performed
four myomectomies during pregnancy, three of
them to remove degenerated tumors. Of Mussey
and Hardwick’s® thirty-two myomectomies
twenty-one were done for necrosis. Reis and
Sinykin^® removed twenty-three tumors in eight-
een operations performed during pregnancy and
eighteen of the tumors were reported as show-
ing degenerative change.

As a rule the acute symptoms of degeneration
last only from ten to fourteen days and in the
vast majority of instances the patient can be
carried through this period without excessive
risk. With the exception of the eight patients
operated upon early in pregnancy none of our
patients was subjected to surgery during the
antepartum period, although 12.5 per cent de-
veloped what we believed to be degenerative tu-
mor changes. All complained of severe uterine
pain and on palpation there was marked tender-
ness in the tumors associated with a definite en-
largement. Treatment consisted of bed rest and
sedation and in all our cases the symptoms dis-
appeared in from one to three weeks. All the
patients in this group were delivered of normal
living infants.

796

Jour. M.S.M.S.

UTERINE FIBROIDS— WILLSON

Effect on Labor

Obviously in these cases the responsibility of
the attending physician increases with the onset
of labor. While the incidence of operative inter-
vention naturally rises, such interference should
be only on the basis of clear-cut indications.
Eisaman^ reported operative delivery due to the
presence of fibroids in 36 per cent, Mussey and
Hardwick® 39 per cent and CampbelP 29 per
cent. Our total operative incidence in this series
was thirty-four per cent. Included in these oper-
ative procedures were five cases in which low
forceps were used to complete the delivery in
primiparse, but were not done because of inter-
ference by the^ fibroids. When these are sub-
tracted from the total the operative deliveries
made necessary by the presence of fibroids in
our series is reduced to twenty-two per cent
(Table II).

TABLE II. COMPARATIVE OPERATIVE INCIDENCE

DUE TO FIBROIDS

No.

Percentage Cases

Campbell (1933) 29.2 82

Eisaman (1934) 36 71

Mussey Hardwick (1935) 39 97

Willson (1940) 22 53

I

The operative deliveries made necessary by
interference from the fibroids consisted of :
(1) two Porro cesarean sections, one in a patient
with uterine inertia associated with the tumors
and the other because of a large fibroid mass low
in the pelvis; (2) two versions with extraction,
the indications being inertia and premature sepa-
ration of the placenta; (3) one breech extrac-
tion; (4) one Duhrssen’s incision and high for-
ceps after an 86-hour labor; (5) one manual
dilatation of the cervix and mid-forceps extrac-
tion after a 36-hour labor; (6) one mid-forceps
extraction, and (7) one manual rotation of the
fetus from a posterior position (Table III).

TABLE III. OPERATIONS FOR DELIVERY

Porro section 2

Duhrssen’s incisions 1

High forceps extraction

Manual dilatation cervix 1

Mid forceps extraction

Forceps rotation POP to OA 1

Version and extraction 2

Mid forceps extraction 1

Breech extraction 1

Manual rotation ORP to OA 1

Low forceps extraction 5

The increased operative incidence in patients
with uterine fibroids may be attributed to :

October. 1941

(1) Inertia. A uterus studded with tumors is
unable to work as efficiently as a normal uterus
in which there is nothing to interfere with the
action of the muscle fibers. In some instances
the body of the uterus may be made up almost
completely of fibroids at the expense of muscle.
In this type a true primary inertia may be en-
countered. The characteristics of the contrac-
tions in our patients are summarized in Table IV.

TABLE IV. CHARACTER OF CONTRACTIONS

Normal Weak Irregular Weak and Irregular

48.8% 23% 12.9% 15.4%

In most cases the pains were of good quality if
there were only a small number of tumors, but in
those patients whose uteri contained many nod-
ules the contractions were poor. Most of the
patients whose pains were classified as normal or
weak had a normal duration of labor, but those
in the last two groups (irregular, and weak and
irregular) were more apt to have long labors.
Despite the fact that the evaluation was made
only by observation of the patient, the type of
labor corresponded closely in almost every in-
stance to the type of contractions recorded.

(2) Abnormal Presentation. There is usually a
higher percentage of abnormal positions in these
patients. Campbell reported sixty-two per cent
cephalic, 2.4 per cent face, 12.2 per cent breech,
and 4.8 per cent transverse. In our patients there
was less deviation from the normal (Table V).

TABLE v. POSITION

OLA ORP ORA OLP POP MV B T

36.8 21 13.1 2.6 5.3 2.6 5.3 2.6

Cephalic

93%

Because of the increase in the number of ab-
normal positions and the high incidence of in-
efficient pains a prolongation of the labor may
occur. Campbell reported 26 per cent with pro-
longed labor and 49 per cent with short labors
in his cases. In our series 52.3 per cent of multi-
para had short labors, 43.4 per cent normal, and
4.3 per cent long (over sixteen hours). The
longest multiparous labor was thirty-two hours.
Of the primipara 33.3 per cent had short labors,
49 per cent normal, and 26.7 per cent long (over
twenty-four hours), the longest being eighty-nine
hours. The average durations of the stages of
labor and the total duration for each group are

797

UTERINE FIBROIDS— WILLSON

shown in Table VI and it is of interest to note
that in this series both are well within the ac-
cepted normal limits.

TABLE VI. ^AVERAGE DURATION OF LABOR

First Second Third Total

Stage Stage Stage Duration

Primipara 20 h. 42 m. 1 h. 30 m. 14.4 m. 22 h. 26 m.

Multipara 7 h. 10 m. 28 m. 18.3 m. 7 h. 56 m.

Multiple small fibroids scattered throughout
the uterine musculature may prevent firm con-
traction following the expulsion of the placenta
and consequently postpartum hemorrhage must
be guarded against.

The endometrium over large submucous
fibroid nodules may be atrophic in character
and unable to respond normally to the stimulus
of pregnancy. If the placenta is attached in this
area it may become partially adherent and man-
ual removal may be necessary. CampbelR re-
ported postpartum hemorrhage in 31.7 per cent
of his eighty-two patients and adherent placenta
in eight. In Watson’s^® series postpartum hemor-
rhage occurred three times and adherent pla-
centa twice in 157 cases.

The estimated blood loss at the time of de-
livery in our series was under 500 c.c. in each
instance and over 300 c.c. in only eight, or 20
per centi Atonicity of the uterus following de-
livery' of the placenta occurred twenty-four
times, but in all instances the bleeding was read-
ily controlled by the use of oxytoxic drugs. The
placenta was adherent in two instances, necessi-
tating removal in both cases. Low implantation
of the placenta, as evidenced by rupture of the
membrane at the border of the placenta, was
noted six times ; partial premature separation of
the placenta four times and partial placenta pre-
via twice.

Effect on the Puerperium

The outstanding complication of the puerpe-
rium is stated to be degeneration of the tumor
caused by the decreased filood supply as the
uterus contracts and involutes. Because of the
diminished circulation the indiscriminate use of
oxytoxic drugs should be carefully weighed. If
a uterine stimulqnt is indicated it would appear
desirable that this be given in small and infre-
quent doses.

In Campbell’s cases five myomectomies and
three hysterectomies were done during the post-

partum period for degenerated tumors. In six of I
our patients temperature elevation associated n
with marked tumor tenderness was noted during |
the postpartum period, but all six recovered I
without surgical intervention. The average num- 1
ber of febrile days postpartum was 1.7, the long-
est being for fourteen days.

The average number of postpartum hospital
days for all patients was 15.8, the longest being
twenty-nine days in a patient who had been de-
livered by Porro cesarean section. This is a
much shorter period of hospitalization than was
reported by Eisaman.^ In his series those who
delivered spontaneously remained in the hospital
14.5 days, those with abdominal operations nine-
teen days and those with vaginal operations 26.3 ^
days.

Involution of the fibroid uterus is definitely
delayed. It was the opinion of the various exam-
iners who discharged our patients that in 83 per
cent there was subinvolution of the uterus in ad-
dition to the palpated fibroid. This delay of nor-
mal involution may be due partly to interference ,
with the normal mechanism of involution caused
by the presence of tumors in the uterine wall.

Mortality

The goal toward which every obstetrician
strives is the reduction of both fetal and mater-
nal mortality. Campbell reported a maternal
mortality of 3.65 per cent in eighty-two cases of
pregnancy complicated by fibroids, Mussey and
Hardwick 2 per cent in ninety-seven cases, and
Watson 3.2 per cent in 157 cases. In our series
of fifty-three cases treated in a more conserva-
tive manner there were no maternal deaths.

Four babies delivered after the period of via-
bility were lost. One died of aspiration pneumo-
nia on the third day of life. The remaining three
infants were stillborn, and in each instance the
fetal heart was not heard when the patient re-
ported to the hospital in labor. All three were
found macerated at delivery. The longest of
the four labors was twelve hours and all ter-
minated spontaneously. The placenta in two of
the cases was normal, but in the third several
small infarcts were noted. The total fetal loss,
including all the previable infants was sixteen, j
or 30 per cent. If the eight infants sacrificed by |
hysterectomy and the four abortions are siA- 1
tracted from this, the fetal mortality for viable
infants is reduced to 7.6 per cent.

798

Tour. M.S.M.S.

UTERINE FIBROIDS— WILLSON

Summary

Although fibroids may be a formidable com-
plication of pregnancy the majority offer no diffi-
culty if they are managed properly. Interference
with the tumors during the antepartum period is
rarely indicated and before any operative pro-
cedure is attempted careful evaluation of the
whole problem is essential. During pregnancy
the removal of a growth which may obstruct
labor is rarely desirable, but if the operation is
performed the operator should be fully aware of
the risk he is assuming. In a series of cases re-
ported by TroelP^ the maternal mortality was

0.9 per cent higher with myomectomy than with
hysterectomy during early pregnancy. Naturally
the mortality is less with the removal of pe-
dunculated subserous tumors than of those im-
bedded in the uterine wall, but subserous tumors,
unless very large, prolapsed into the pelvis, or
with pedicle twists, rarely cause trouble.

Although expectant treatment will result in a
marked reduction of operative deliveries, the ob-
stetrician must be prepared to interfere during
labor should the indication arise. Patients with
large tumors low in the uterus may require ab-
dominal delivery at term. Many times, however,
the tumor rises out of the pelvis as the lower
uterine segment develops and the delivery will
terminate spontaneously. If a cesarean section is
necessary the problem of what to do with the
fibroids must also be considered. Huber and Hes-
seltine,^ presenting figures collected from the
literature, found a maternal mortality of 15.4
per cent with cesarean section and myomectomy
as compared with 3.4 per cent for cesarean sec-
tion and hysterectomy. Of their own cases eight
Porro operations were performed with no deaths
while in two cesarean sections with myomectomy
one death occurred. These figures emphasize the
fact that the removal of tumors at the time of
abdominal delivery is less safe than hysterec-
tomy.

Although the tumors may undergo a degenera^
tive change during the puerperium when their
blood supply is suddenly reduced, our results
with the conservative care of these cases suggest
that the dangers of postpartum necrosis have
been exaggerated. If operation becomes neces-
sary the uterus should be removed in most in-
stances, Huber and Hesseltine reported thirteen
postpartum hysterectomies without mortality and
ten myomectomies with one death.

As the incidence of operative deliveries in-
creases the fetal mortality rate rises. With the
development of a more conservative attitude in
the management of pregnancy complicated by
uterine fibroids more infant as well as mater-
nal lives are being conserved. This factor
alone justifies a less radical type of care.

Conclusions

1. Fifty-three cases of pregnancy complicated
by uterine fibroids are presented.

2. Although a small percentage of patients
with fibroids will require hysterectomy early in
pregnancy the majority can be carried to term
satisfactorily. Therapeutic abortion and myo-
mectomy are rarely indicated.

3. Symptoms of degeneration in the fibroids
do not always indicate the necessity for inter-
ference. 12.5 per cent of the patients in this se-
ries showed such symptoms but all were carried
to term without operation and all were delivered
of normal children.

4. The presence of fibroids requires more
frequent operative delivery, but every effort
should be made to avoid radical interference.
The incidence of operative deliveries due to
fibroids in this series was 22 per cent.

5. Conservative management of pregnancies
complicated by fibroids will lead to a decrease in
maternal and fetal risk. In this series there
were no maternal deaths and the fetal mortality
for viable infants only was 7.6 per cent.

Bibliography

1. Campbell, R. E. : Fibroids complicating pregnancy and la-

bor. Am. Jour. Obst. and Gynec., 26:1-16, (July) 1933.

2. Eisaman, J. R. : Pregnancy complicated by fibroids. Am.

Jour. Obst. and Gynec., 28:561-567, (Oct.) 1934.

3. Emge, L. A. : The influence of pregnancy on tumor

growth. Am. Jour. Obst. and Gynec., 28:682-697, (Nov.)
1934.

4. Huber, C. P., and Hesseltine, H. C. : Fibromyomata, op-

erative management at term. Surg., Gynec. and Obst., 68:
699-702, (May) 1939.

5. Lynch, F. W. : Fibroids and ovarian cysts complicating

pregnancy. Calif, and West. Med., 35:415-420, (Dec.) 1931.

6. Mussey, R. D., and Hardwick, R. S. : The outcome of

pregnancy complicated by fibromyomata. Am. Jour, (Dbst.
and Gynec., 29:192-198, (Feb.) 1935.

7. Pierson, R. N. : Fibromyomata and pregnancy. Am. Jour.
Obst. and Gynec., 14:333-344, (Sept.) 1927.

8. Pinard quoted from : Lobenstine, R. W. : Fibromyomata

complicating pregnancy, labor and the puerperium. Am.
Jour. Obst., 63:67-83, (Jan.) 1911.

9. Polak, J. O. : The influence of fibroids on pregnancy and

labor. Surg., Gynec. and Obst., 46:21-29 (Jan.) 1928.

10. Rei.s, R- A., and Sinykin, M. B.: Myomectomy during
pregnancy. Am. Jour. Obst. and Gynec., 39:834-839, (May)
1939.

11. Studdiford, W. E. : Pregnancy in the fibroid uterus. Jour.
Med. Soc. N. J., 32:424-427, (July) 1935.

12. Troell quoted from: Cuthbert Lockyear: Fibroids and al-

lied tumors. MacMillan and Co., London, 1918.

13. Watson, B. P. : Fibroids complicating pregnancy and labor.
Am. Jour. Obst. and Gynec., 23:351-360, (Mar.) 1932.

October, 1941

799

VARICOSE VEINS— ROSENZWEIG ET AL.

Varicose Veins

Allergic Reactions in Injection
Treatment*

Saul Rosenzweig, M.D., Meyer Ascher, M.D., and
Louis Zlatkin, M.D.

Detroit, Michigan

Saul Rosenzweig, M.D.

M.D., University of Michigan, _ 1924. Asso-
ciate physician, Detroit Receiving Hospital.

Senior physician. Children’s Hospital of
Michigan. Attending physician, Cardio-V oscu-
lar Clinics, North End Clinic. Diplofnate
' American Board of Internal Medicine. In-
structor Wayne University Medical School.

Fellow, American College _ of Physicians.

Member, Michigan State Medical Society.

Meyer S. Ascher, M.D.

M.D., Wayne University College of Medi-
cine, 1930. Associate physician. North End
Clinic. Associate member American Society
for Study of Allergy. Member, Michigan
State Medical Society.

Louis Zlatkin, M.D.

A.B., University of Michigan, 1931. M.D.,
University of Michigan, 1935. Associate phy-
sician North End Clinic. Member, Michigan
State Medical Society.

■ The method of obliterating varices by the
injection of sclerosing solutions has grown in
popularity and repute for more than a decade.
At first these solutions were very unsatisfactory
because of local irritation, severe cramps, in-
dolent sloughs, etc. However, other agents with-
out these disadvantages were soon introduced ;
such solutions are sodium morrhuate, sodium
ricinoleate, and sodium monoethanolamine (mon-
olate) . These materials are soaps of either natural
or synthetic cod liver oil, castor oil, and olive oil
respectively. For the obliteration of varicose
veins these solutions are effective, generally pain-
less, and harmless, unless too much is deposited
extravascularly, even in which case slough is
quite rare. Sodium morrhuate produces the least
untoward local reaction and is the safest of these
four solutions to use, especially in the hands of
the less-experienced operator. Deaths from em-
bolic phenomena are most rare. Proper selection
of cases and post-injection care have either en-
tirely eliminated or greatly reduced the compli-
cations and hazards. However, in this paper we
are reporting the occasional natural or acquired
allergy to these solutions which we have encoun-
tered.

History

Allergy to sclerosing solutions has been re-
ported extensively in the literature.^'^^ Ritchie,®

•From Cardio-Vascular Clinics, North End Clinic, Detroit.
800

as far back as 1933, classified the types of al-
lergic reactions to sclerosing solutions as (a)
erythematous, (b) gastrointestinal and (c) cir- '
culatory. Zimmerman,^® in 1934, reported seven
cases of sensitivity to sodium morrhuate. In his
series three patients developed reactions follow-
ing the initial injection. In the remaining four
cases the allergy manifested itself only after the
injections had been resumed following a rest
period of several weeks or more. He advised
intradermal skin-testing to determine sensitivity
to preclude the danger of a severe anaphylactic
response in the later type of case. In 1935, Praver
and Becker® observed “untoward reactions in
the form of a cutaneous eruption or a nitritoid
crisis in seven out of 176 patients who received
783 injections of 5 per cent sodium morrhuate
. . . for the . . . obliteration of varicose veins.”
Lewis,® in 1936, also reported a very severe re-
action from sodium morrhuate in a patient who
had completed a series of injections and had just
returned to clear up a few recurrent varicoses. He
reiterated that the greatest care should be exer-
cised in “patients who had previously used the
same solution if a sufficient time had elapsed
to allow the development of a foreign protein
sensitiveness.” Dale,^ in 1937, on the other hand,
reported a severe nitritoid reaction following the
thirteenth in a series of injections spaced at
regular intervals. Moreover, Hatcher and Long,®
mention a case in which reactions occurred only
after the first injection of two separate series
of treatments and none on successive injections.
Traub and Swartz^^ and McCastor and McCas-
tor,’’ in the same year, reported severe anaphylac-
toid reactions to sodium morrhuate. Levi,® in
1938, called attention to the fact that deaths have
followed the use of the same substance. Shel- ■
ley,^® in 1939, described a fatality following the
use of monoethanolamine oleate (monolate). He
also suggested that death following the use of *
sodium morrhuate is not as uncommon as the j
medical literature would indicate. He mentioned '
the fact that one physician from the Medical Ex- :
aminer’s Office in New York City stated that •
he had seen three such deaths in the course of
his duties, none of which have been mentioned
in the medical literature. This experience has
not been noted locally. Holland® and Kadin^
have recently added to the reports of severe
anaphylactoid reactions to that sclerosing agent.

Tour. M.S.M.S. ;

I

VARICOSE VEINS— ROSENZWEIG ET AL.

Agents and Technique

Sodium morrhuate has been accepted as the
solution of choice in this clinic and it has been
used ver>’ extensively for the obliteration of

by the preceding injection. Treatments were gen-
erally given at weekly intervals. The patient was
discharged when all the varicosities were oblit-
erated. In a number of patients, where recur-

TABLE I.

Annual Incidence of Allergic Reactions to Intravenous Sodium Morrhuate
for the Obliteration of Varicose Veins

Year

No. of
Reactions

No. of Pts.
Treated*

Incidence of
Reactions to
No. of Pts.
Treated

Sodium
Morrhuate
Total No. of
Injections

Incidence of
Reactions to
Total No. of
Injections

1930

0

25

0

450

0

1931

0

83

0

1,087

0

1932

0

134

0

1,327

0

1933

0

119

0

1,201

0

1934

0

125

0

1,114

0

1935

3

86

3.49%

1,168

0.275%

1936

3

82.

3.66%

1,030

0.291%

1937

1

81

1.23%

954

0.148%

1938

2

96

2.08%

1,052

0.190%

1939

6

85

7.06%

886

0.677%

1940

1

22

4.54%

241

0.415%

Total

16

938

1.706%

10,510

0.152%

*New admissions.

varicosities. In a small number of cases, where
an incompatability was found or experience in-
dicated, sodium ricinoleate was used. Since
1930, using sodium morrhuate for the most part,
we have treated 938 cases and have given 10,510
injections (Table I). The size of the usual dose
varied from 0.5 c.c. of a 5 per cent solution up
to 2.0 c.c. of a 10 per cent solution. The num-
ber of true reactions encountered were sixteen,
giving an incidence of 1.706 per cent of the
number of cases treated, and 0.152 per cent of
the number of injections given.

In the selection of cases for injection of vari-
cosities of the lower extremities, the usual safe-
guards in the history, and both local and general
examinations were made. Special emphasis was
placed on the integrity of the deep venous cir-
culation. If there was no history of allergv^, 0.5
c.c. of a 5 per cent sodium morrhuate solution
was then injected intravenously into the lowest
varix. On subsequent visits the amount was
gradually increased up to 2.0 c.c., the increase
depending upon the degree of thrombosis caused

rences of some varicosities were present, treat-
ment was resumed with the original 0.5 c.c. of
5 per cent sodium morrhuate solution.

Reactions

Seven reactions followed the resumption of
treatment, three occurring between the second
and fourth injections. Two reactions followed
the initial injection of sodium morrhuate; and
one person first experienced allergic symptoms
only after the twenty-third injection. In two in-
stances, reactions occurred on the second and
fourth injections of the first series respectively,
and occurred in three cases on the second to
fourth injection upon the resumption of treat-
ment instituted to clear up a few recurrent vari-
cosities. In the nine remaining cases the reac-
tions follow’ed only after a successive number of
injections given at regularly-spaced intervals
(Table II).

In most instances of sodium morrhuate sen-
sitivity, an attempt to complete the obliteration
of the varicose veins by sodium ricinoleate was

October, 1941

801

VARICOSE VEINS— ROSENZWEIG ET AL.

made. In two such cases, the patients also de-
veloped an allergy to the sodium ricinoleate on
the second and fourth injection respectively (Ta-
ble III). In the majority of the fourteen remain-

of patients treated) (Table IV). In addition our
incidence of reactions to the total number of
injections was 0.152 per cent compared to 0.894
reported by the same authors.

TABLE II.

Time Relationship of Allergic Reaction to Number of Injections Received

Serial No.
of

Injection

First Series of In;

ections

Resume of Course of
Treatment

First

Injection

2nd — 4th
Injection

5th Plus
Injection

First

Injection

2nd — 4th
Injection

5th Plus
Injection

No. of
Reactions

2

2

5

0

3

4

Incidence

12.50%

12.50%

31.25%

0

18.75%

25.00%

TABLE III.

Atopic Features of Allergic Responses to Sodium
Morrhuate

Criteria

Positive

Negative

Percentage

Positive

Skin Tests
(Intradermal)

2

14

12.50%

Subsequent Allergy
to

Sodium Ricinoleate

2

14

12.50%

Concomitant
Allergy to
Other Substances

•

1

15

6.25%

ing cases that exhibited an allergy to sodium
morrhuate, treatment with sodium ricinoleate was
successful for the obliteration of the varicose
veins. Skin tests for suspected allergy were of
little or no assistance in preventing reactions.
Only two persons, suffering clinical allergy to
sodium morrhuate, gave positive skin reactions
upon intradermal testing. The other individuals
gave negative results. Only one person in this
group had another form of allergy, ragweed hay-
fever. The allergy as with' other allergies was
specific, i. e., was not experienced when a shift
from morrhuate to ricinoleate was made, even
though two patients who were sensitive to so-
dium morrhuate later developed a sensitivity to
sodium ricinoleate.

Our experience with allergic reactions (1.706
per cent of patients treated) compared favor-
ably with the number encountered by Praver and
Becker® who reported seven untoward reactions
in 176 patients who had received 783 injections
of 5 per cent sodium morrhuate (3.97 per cent

802

Types of Reactions

The severity of allergic reactions ranged all
the way from a localized urticaria at the site of
the injection to coma and circulatory collapse.
Allergic reactions to the sclerosing solutions could
be classified as: (a) cutaneous, (b) respiratory,
(c) cerebral, (d) gastro-intestinal and (e) se-
vere anaphylaxis (Table V). A combination of
the types was usually the rule. The cutaneous
type of reaction was the most common of all
the manifestations. It was manifested by either
local or generalized pruritus, erythema and ur-
ticaria. It was also the easiest to control, re-
sponding to small injection of epinephrine, 1 :
1000, or ephedrine sulphate by mouth. Cutaneous
reactions were noted in twelve persons. A case
report illustrating this type of reaction was that
of Case 15 :

Mrs. E. G., aged twenty-one, came to the clinic com-
plaining of bilateral varicosities of one year’s du-
ration. Due to the large size of the varicosities a saphe-
nous ligation was advised. On June 1, 1939, 0.1 c.c. of a
5 per cent solution of sodium morrhuate was injected
in a varix as a test dose for sensitivity. The next
day the patient noted a mild pruritus at the site of the
injection. This disappeared in a short while. On
June 3, 1939, 2.5 c.c. of a 5 per cent solution of sodium
morrhuate was injected into the distal segment of the
left saphenous vein at the time of a saphenous-femoral
ligation. Pruritus over the entire course of the in-
jected vein was immediate. In five minutes giant urti-
carial wheals involving the entire left thigh and leg
was noted. The patient was given 10 minims (0.6 c.c.)
of epinephrine, 1 :KX)0, intramuscularly and ephedrine
sulphate, gr. orally. The urticarial reaction grad-
ually subsided. However, the pruritus remained for
two days. Intradermal skin tests performed at a Jater
date were strongly positive for sodium morrhuate.

Jour. M.S.M.S.

VARICOSE VEINS— ROSENZWEIG ET AL.

The respiratory type of reaction was general-
ly manifested by asthmatic wheezing and cough-
ing. In our group of cases it always accompa-
nied anaphylactic shock. Five persons suffered

action, the patient suffered from abdominal
cramps, nausea, diarrhea and an occasional eme-
sis. Three persons manifested gastro-intestinal
allergy. Two persons in this series showed

TABLE IV.

Incidence of Allergic Reactions to Sodium Morrhuate

Reference

No. of
Reactions

No. of Pts.
Treated

Incidence of
Reactions to
No. of Pts.
Treated

Total No. of
Injections

Incidence of
Reactions to
Total No. of
Injections

North End
Clinic

16

938

1.706%

10,510

0.152%

Praver and
Becker®

7

176

3.977%

783

0.894%

TABLE V.

/

Incidence of Type of Allergic Response to Sodium Morrhuate

No. of

Dermatological

Respiratory

Cerebral

Gastro-

Allergic

Reactions

Allergy

Allergy

Allergy

intestinal

Allergy

Shock

16

12

5

2

3

4

Incidence

75.0%

31.25%

12.50%

18.75%

25.00%

from respiratory symptoms. Case 2 illus-
trates this type of reaction:

Mrs. J. G., aged forty-five, gave a history of extensive
varicose veins of both legs for fourteen years. The
varicosities were so large and extensive that a bilateral
ligation at the saphenous-femoral junction was advised,
and on June 6, 1936, that operation was performed. The
remaining patent varicosities were treated by injec-
tions of sodium morrhuate. Even though she had re-
ceived fourteen weekly injections of 5 per cent sodium
morrhuate in doses varying from 0.5 to 2.0 c.c., the
fifteenth injection on October 22, 1936, elicited imme-
d.iate complaints of dizziness, difficulty in breathing and
a tightness in the chest. There was spasmodic cough-
ing and some expectoration. On examination, diffuse
rales were he^rd over the entire chest, and the breath
sounds were indistinct. The radial pulse was slow and
poor in quality. The patient was given 10 minims (0.6
c.c.) of epinephrine, 1:1000, intramuscularly. In twen-
ty minutes the chest complaints were less marked.
The injection of epinephrine was repeated. Recovery
proceeded rapidly, the dizziness and pulmonary edema
gradually disappearing with complete recovery within
a relatively short time. An intradermal skin test per-
formed two weeks later was very positive.

In the ordinary gastro-intestinal type of re-

OCTOBER, 1941

symptoms which designated cerebral involve-
ment.

The most severe of all allergic reactions was
anaphylactic shock with resultant coma, collapse,
loss of pulse, and in some cases convulsions and
shock. Anaphylactic shock may, or may not, be
preceded by cutaneous, respiratory, cerebral, or
gastro-intestinal reactions. A gastro-intestinal
type of reaction preceded the anaphylactic shock
in Case 5.

Mrs. R. G., aged fifty-two, gave a negative history
of allergy, but a positive history of diabetes mellitus.
Chief complaint was of marked varicose veins, pres-
ent for twenty years. During the period from Novem-
ber 14, 1930, to July 3, 1932, the patient received a
number of injections of 20 per cent saline-glucose solu-
tion with moderate success. She returned on April 21,
1933, and was given weekly injections of 1-2 c.c. of
5 per cent sodium morrhuate. Returned a second time
on March 14, 1935, for weekly injections of the same
sclerosing agent. On April 4, 1935, she received 1.5
c.c. of 5 per cent sodium morrhuate. About seven min-
utes later, the patient felt dizzy and warm, complained
of generalized weakness, a sinking sensation in the
abdomen, nausea and upper epigastric pain. After
a few minutes she collapsed and was given 10 minims

803

TABLE VII. SUMMARY OF CLINICAL DATA

VARICOSE VEINS— ROSENZWEIG ET AL.

804

i

VARICOSE VEINS— ROSEXZWEIG ET AL.

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(0.6 c.c.) of epinephrine, 1 :1000. Five minutes later
the patient became drowsy and semicomatose, followed
by twitching movements of the mouth. The left por-
tion of the face became flaccid. The entire chest was
filled with diffuse rales. Thirty-five minutes after the
onset of symptoms, the blood pressure reading was

TABLE VI.

Influence of Sex on Incidence of Allergy
to Soditim Alorrhuate

Sex

No. of Pts.
Treated

No. of
Reactions

Incidence of
Reactions

Male

275

1

0.363%

Female

663

15

2.262%

Total

938

16

1.706%

50/?. The radial pulse was of poor thready quality.
The injection of epinephrine was repeated. Ten minutes
later the patient became semiconscious with poor orien-
tation. The blood pressure reading was 82/46. The
injection of epinephrine was repeated 25 minutes later.
The blood pressure rose to 98/70. The patient was
then given. 20 c.c. of a 50 per cent solution of glucose
with 5 units of insulin intravenously. Approximately
90 minutes after the onset of the symptoms the patient
regained full consciousness with a blood pressure read-
ing of 114/68. The pulse, however, was still weak and
irregular, with no alleviation of the epigastric pain.
The patient’s condition rendered hospitalization for
two days advisable.

Sex appeared to be a factor in our series.
The ratio of females to males in our series aver-
aged 2.41 to 1, there being 663 women and 275
men. Only one of the men treated suffered a
reaction, an incident of 0.363 per cent ; while
15 women of 663 treated, an incidence of 2.262
per cent had reactions (Table VI). Thus women
were 6.2 times as allergic as the men.

Conclusion

The usual allergic reaction does not often put
the patient’s life in jeopardy. Among the six-
teen reactors, there was one instance of anaphy-
lactic shock, while three other patients suffered
syncope. The underlying mechanism of the pro-
duction of allergy to sodium morrhuate is not
clear. It bears a marked similarity to the pro-
duction of serum sickness, since only two of the
sixteen reactors suffered from an allergic reac-
tion following the first administration of the
antigenic substance. The other fourteen cases
were instances of acquired allerg>q occurring
as far along in the course of treatment as the

805

October, 1941

FRACTURES OF LONG BONES— MOORE AND VAN PERN IS

twenty-third injection. Moreover only two of
the reactors gave positive skin reactions to the al-
lergen, and then only after they had suffered
reactions. Whether the allergy is due to a pro-
tein fraction of the sclerosing substance or to the
formation of a hapten is unimportant. The dan-
ger of a reaction is always present and generally
unpredictable, and, therefore, the more distressing
to both physician and patient. Any symptoms
referable to allergy should be sufficient indica-
tion and warning to discontinue treatment with
that particular sclerosing agent.

The treatment of the mild reactions is purely
symptomatic ; small doses of epinephrine shorten
the episode as well as relieve the symptoms;
ephedrine by mouth can be helpful. The se-
vere reactions are acute medical emergencies;
here again epinephrine is the most valuable agent,
and should rapidly be used in full therapeutic
doses ; ephedrine and similar drugs should not be
employed here. No other chemicals are of any
significant assistance. Supportive measures
should of course be employed ; external heat and
intravenous glucose seem to be of distinct help.
No attempt at desensitization was attempted in
any of our cases ; we preferred to switch safely
to another thrombosing solution.

Summary

1. Nine hundred thirty-eight patients suffering
from varicose veins of the lower extremities were
given 10,510 injections of sodium morrhuate
from 1930 to 1940. Sixteen allergic reactions to
that substance occurred.

2. Two reactions followed the initial injection
of the sodium morrhuate; two occurred on the
second to the fourth injection; five occurred
after the fifth injection ; three occurred on the
second to fourth injections following the resump-
tion of treatment, and four after the fifth in-
jection following the resumption of treatment.

3. Skin tests were positive in only two cases;
two reactors subsequently gave reactions to so-
dium ricinoleate; and one person also had hay-
fever.

4. Our incidence of reactions compared most
favorably with the incidence reported elsewhere.

5. Allergy to sodium morrhuate presented it-
self symptomatically as (a) dermatological, (b)
respiratory, (c) cerebral, (d) gastro-intestinal,
and (e) anaphylactic shock.

6. Sex appeared to be a factor in our series

of cases. Women were markedly more suscepti-
ble to reactions than men.

Bibliography

1. Dale, M. L. : Reaction due to the injection of sodium

morrhuate. Jour. A.M.A., 108:718-719, (Feb. 27) 1936.

2. Hatcher, M. B., and Long, H. W. : Unfavorable reaction
(especially paralysis of arm) from sodium morrhuate.
Jour. Med. Assn. Georgia, 26:427-428, (Aug.) 1937.

3. Holland, G. A.: Reactions from sodium morrhuate in the
sclerosing of varicose veins. Canad. Med. Assn. Jour., 41:
262, (Sept.) 1939.

4. Kadin, Maurice: Sodium morrhuate; severe reaction to in-

jection. Mich. State Med. Jour., 39:561, (Aug.) 1940.

5. Levi, David: Injection Treatment of Varicose Veins.

Practical Procedures. Rolleston, Humphrey & Moncrieff,
A.A., Pub. Eyre and Spottiswoods, London, 1938.

6. Lewis, K. M. : Anaphylaxis due to sodium morrhuate.

Jour. A.M.A., 107:1298, (Oct. 17) 1936.

7. McCastor, J. T. N., and Mc(3astor, M. E. : Reaction to

sodium morrhuate injection. Jour. A.M.A., 109:1799-1800.
(Nov. 27) 1937.

8. Praver, L. L., and Becker, S. W. : Sensitization phenomena
following use of chemical obliteration of varicose veins.
Jour. A.M.A., 104:997, (Mar. 23) 1935.

9. Richie, Allison. Treatment of varicose veins during preg-
nancy. Edinburgh Med. Jour., p. 157, (Nov.) 1933.

10. Shelley, Harold J. : Allergic manifestations with injection

treatment of varicose veins — death following an injection
of monoethanolamine oleate (monolate). Jour. A.M.A.. 112’
1792, (May 6) 1939.

11. Traub, L. E., and Swartz, W. B., Jr.: Collapse complicat-
ing injection of sodium morrhuate, N. Y. State Jour. Med.
37:1506-08, (Sept. 1) 1937.

12. Zimmerman, L. M. : Allergic-like reactions in obliteration

of varicose veins. Jour. A.M.A., 102:1216-1217. (Aoril 141

irto A 9 \ if /

^=[VlSMS^_

A Method for Correction of
Angulation in Fractures
of Long Bones

By V. M. Moore, M.D.

Grand Rapids, Michigan
Paul A. Van Pernis, M.D.

Chicago, Illinois

Veenor M. Moore, M.D.

A.B., and M.D., University of Michigan,

1911. Member, American Board of Radiology
and Michigan State Medical Society.

Paul A. Van Pernis, M. D.

A.B., Hope College, 1935. M.D., Rush

Medical^ College, 1939. John Jay Borland
Fellow in Clinical Research at St. Luke’s IJos-
pital, Chicago.

■ The general practitioner frequently encoun-
ters some difficulty in correcting angulation de-
formities following fractures of long bones. We
wish to emphasize a method well known to ortho-
pedic surgeons; namely, cast wedging. We be-
lieve that an accurate correction is possible by
simple means.

After a fracture is reduced, checkup x-ray
films should be taken to determine if proper
alignment of fragments has been obtained. The
radiologist should determine, by means of a pro-
tractor, any angulation present in one or both
planes, and state the degree and direction of
angulation in his report to the physician. This
done, correction of any existing angulation then

806

Jour. M.S.M.S.

FRACTURES OF ANKLE JOINT— LAVENDER

is made possible by a number of methods. We
have suggested two methods and in twenty cases
where they have been utilized excellent results
have been obtained.

Method I. A — Degree of angulation. B — Wedge. A = B.

Method II. Abe — Line of angulation, abd — Corrected line
ef. Circular cut.

Method I

A wedge of cardboard or thin lead is cut to
correspond exactly to the degree of angulation
measured from the film of the bones involved in
the fracture. The cast is then cut circularly at
the fracture site three-fourths of its circumfer-
ence and the distal portion of the cast with its
encased soft tissues and bones is moved in the
proper direction so that the cardboard wedge fits
snugly into the widened circular cut. An assist-
ant then holds the extremity in the new position,
or the position is maintained by the use of a
Hawley table. New plaster is applied over the
site of the inserted wedge and the extremity held
in position until drying is complete. If angula-
tion is present in two planes, another circular
cut immediately above or below the previous cut
in the cast is made and the proper wedge is in-
serted at right angles to the first wedge and the
above procedure repeated. We have had no ill
effects due to soft tissue swelling at the fracture
site. This method, of course, is only applicable

to non-comminuted fractures unless pin traction
is employed.

Method II

A second method is to draw lines on the cast
showing the degree of angulation as seen on the
x-ray film. The cast is then cut circularly at the
site of fracture and the lower fragments bent un-
til the previously drawn angulated line becomes
a straight line. If the angulation is in two planes
the same procedure may be repeated for the
other plane of angulation. If angulation is only
in one plane it is well to draw a straight line
in the other plane so that during correction one
does not make a new angulation in this second
plane. This will not occur if care is taken to
keep the latter line perfectly straight. The method
is particularly useful where pin traction is em-
ployed.

= [^SMS

Severe Fractures of the
Ankle Joint

Conservative Management and a
Presentation of Typical Cases

Howard C. Lavender, M.D.

Kalamazoo, Michigan

Howard Lavender, M.D.

B.A., Vanderbilt University, 1928. M.D.,

Vanderbilt University Medical School, 1932.

Member of Surgical Staff, Bronson and Bor-
gess Hospitals, Kalamazoo. Member, Michigan
State Medical Society.

■ It is well known that fractures of the ankle
may at times offer very difficult problems.
The end results have often been a permanent
disability in the patient and a sad disappointment
to the physician. Mutilation of the bones and
soft tissues about the ankle, produced by direct
violence, represent the worst injuries. Fortu-
nately, such occurrences are infrequent, but when
they are seen, one has to make the best of a
bad situation.

The many types of ankle injuries are well de-
scribed in most of the modern textbooks®’^® and
Ashhurst and Bromer^ gave a complete classifica-
tion of ankle fractures based on the applica-
tion of the force which may produce them. In
a recent publication, Carothers^ has suggested a

October, 1941

807

FRACTURES OF ANKLE JOINT— LAVENDER

classification that is rather simple and based on
injuries of the ankle joint with or without dis-
placement of the astragulus.

The most serious fracture of the angle pro-
duced by indirect violence is the one in which
both internal and external malleoli are separated
and displaced together with the fracture and dis-
placement of a portion of the lower, posterior
articulating surface of the tibia. Henderson and
Stuck® in 1935 called it a “trimalleolar fracture,”
which is a convenient descriptive term but not
anatomically correct, since the lower, posterior
joint lip of the tibia is not a true malleolus. Al-
though this injury of the ankle was described by*
Sir Astley Cooper in 1832, Cotton®’®’^ in 1915
stimulated new interest and pointed out the se-
rious consequences that arise if the posterior
dislocation was not recognized and reduced.
This new interest has been manifested to a large
extent in attempts to properly treat this injury
so that the best results may be obtained.

There are those who believe an open reduction
and internal fixation of the posterior tibial frag-
ment is the best means of maintaining a satisfac-
tory alignment of the fracture. Lounsberry and
Metz®’^^’^® first suggested this method, which is
now used almost routinely by some, particularly
when the posterior tibial fragment involves one-
third or more of the lower articulating surface.
On the other hand there are those who have had
equal success with combined manipulation and
traction methods and Bohler® contends that open
reduction is never indicated. However, it is
obvious that the object in both methods is to
anatomically reduce and maintain the alignment
of the posterior tibial fragment, which is the fac-
tor that gives the most trouble and makes the
fracture a mean one to- deal with. The literature
during the past few years contains a variety of
discussions on the management of this injury.
To study the methods of treatment gives one the
impression that some seem too radical and others
too conservative. To attempt to achieve success
in the treatment of a trimalleolar fracture simply
by manipulation and application of a plaster cast,
one certainly has to be an optimist. Ou the
other hand, the routine use of open reduction
and fixation in treating every case, makes one ap-
pear to be a pessimist. Therefore, it seems that
if a standard or routine method would be used,
it is better to take the middle ground. I have
found the use of manipulation with traction to

808

be quite adequate in the meanest trimalleolar
fractures of the ankle and the results obtained
have been gratifying.

In the treatment of fractures of the ankle the
mechanism of the force producing the fracture
should be taken into account as this knowledge
facilitates the reduction. Indirect force on the
plantar flexed foot, or sometimes a combination
of extreme plantar flexion, abduction and ex-
ternal rotation, is responsible for a trimalleolar
fracture. The astragulus is driven against the
lower, posterior, articulating margin of the tibia
resulting in a fractured fragment at this point of
the tibia. Continuation of the force on the un-
restrained foot causes a severe tug on the deltoid
and lateral ligaments which produces the frac-
tures of the medial and lateral malleoli and a
posterior dislocation of the astragulus. If the
fracturing force is directed more directly against
the lower end of the tibia, then a comminuted or
T- fracture may occur associated with injury to
the tibiofibular ligament. Rupture of the liga-
ment between the lower end of the tibia and
fibula widens the space between the bones at this
point and the astragulus dislocates laterally. A
force directed anteriorly against the lower, ar-
ticulating surface of the tibia may produce a
fractured fragment of the anterior margin with
forward dislocation of the astragulus; however,
such injury is very uncommon. Therefore, in
reduction it is necessary to use manipulation that
opposes the forces that produced the injurj\

Even in trimalleolar fractures with dislocation
of the astragulus, it is possible to have different
degrees of injury. A “classical” fracture is the
worst in that the tibial fragment usually .com-
prises one-third or more of the articulating
surface, whereas a “minimal” fracture consists
of a much smaller tibial fragment. This distinc-
tion in the size of the tibial fragment has been
a deciding factor in the treatment, indicating
open reduction in the classical type and more
conservative methods for the minimal fracture.

No attempt is made to suggest any new method
of treating fractures of the ankle or to detract
from various treatments that are now in use and
giving good results. The purpose is simply to
demonstrate, by these cases, the results obtained
by the use of manipulative reduction and main-
tenance with the aid of steel pins used in trac-
tion and incorporated in a plaster cast. I be-
lieve the method to be safe, simple and quite

Jour. M.S.M.S.

FRACTURES OF ANKLE JOINT— LAVENDER

satisfactory in the treatment of some of the
worst fractures of the ankle.

Technique

Early reduction is always advisable, unless, of
course, other more severe injuries demand first
attention. Soft tissue swelling, pain and some

widened by injury to the tibiofibular ligament.
Internal rotation of the foot usually aligns the
lower end of the fibula and adduction returns the
medial malleolus of the tibia to its normal posi-
tion as well as to approximate the lacerated fibers
of the deltoid ligament. Radiographic studies
should then reveal the astragulus fitting snugly

degree of shock are minimized by early treat-
ment. The patient lying on his back, the foot
and leg are surgically prepared. Novocain is
infiltrated into the skin over the os calcis and
upper portion of the tibia medially and laterally.
Infiltration may then be made into the hema-
toma within the ankle joint and shortly pain is
entirely relieved. A steel pin is placed through
the upper, posterior portion of the os calcis and
another through the tibia just below the tubercle.
To retract the skin toward the knee before in-
serting the upper pin will avoid tension against
the skin at the pin holes. The foot and leg is
gently supported as it is placed in a traction
apparatus and the pins locked in place. Support
is continued until sufficient traction is made to
reduce the astragulus. The foot and leg is then
elvated until the knee is flexed from forty-five
to seventy degrees from complete extension and
thereby the gastrocnemius muscle is well relaxed.
The foot may then be moved without restraint.
Digital pressure over the tibial fragment and
movement of the foot to relax the tendons over
it will disengage the fragment and contribute
to the ease of its replacement. The foot then is
slightly dorsi-flexed for a posterior tibial frag-
ment or plantar-flexed for an anterior fragment,
causing tendon pressure over the fragment to
aid in holding it in place. Bilateral pressure with
the palms of the hands or a padded Forrester
clamp will restore normal relation of the tibia
and fibula if the space between them has been

in the mortise formed by tibia and fibula and the
posterior or anterior tibial fragment must restore
a smooth articulating surface. Plaster is then
applied following a light padding over the upper
portion of the fibula, the patella, the ankle me-
dially and laterally, the Achilles tendon, the plan-
tar surface of the foot and the heel. The steel
pins are incorporated in the plaster which is
wound from the toes to the middle of the thigh.
The foot, leg and knee are encased in whatever
position they may be when the satisfactory reduc-
tion has been obtained, as any change to a neutral
position may result in the loss of the anatomical
alignment. Shortly, when the plaster has set, the
leg is removed from the traction apparatus and*
the patient sent to his room. The foot and leg
is elevated rather high on pillows to allow re-
cession of the swelling of the soft tissues. A
window cut in the cast over the anterior portion
of the ankle and knee adds to the patient’s com-
fort. Of course, close observation of the cir-
culation in the extremity is watched for at least
forty-eight to seventy-two hours, as a circular
cast always carries the danger of being too tight.
Hospitalization after reduction usually affords
more convenience to the physician ; however, it
is not imperative and the patient may convalesce
at his home if he so desires. The cast should
not be removed for five or six weeks. After
this time a lighter, skin cast with a walking iron
should be applied with the foot in a neutral posi-
tion and the knee only slightly flexed. The walk-

OCTOBER, 1941

809

FRACTURES OF ANKLE JOINT— LAVENDER

ing cast may be used for another five or six
weeks, after which weight bearing on the ankle
is allowed. A leather ankle brace or a high top

der spinal anesthesia, the fracture was manipulated to
disengage the fractured fragments and then reduction
by traction and molding of the ankle was carried out.
A good result was obtained in this case. (See Fig. 3.)

1

shoe with an arch support is desirable for two
or three months.

Case 1. J.V.W., male, age 22, case number 34721.

Trimalleolar fracture of the right ankle produced by
sliding into a base during a game of baseball.. Im-
mediate reduction and final result good. (See Fig. 1.)

Case 2. M.G., male, age 45, case number 59283. Tri-
malleolar fracture of the right, angle. The patient
slipped on a wet tile floor. The foot was plantar
flexed and externally rotated as he sat forcefully on
the foot in the fall to the floor. Immediate reduction
and a good result. (See Fig. 2.)

Case 3. R.K., male, age 28, case number 43131.

Severely comminuted fracture of the right ankle. The
patient was in an automobile accident. The patient was
riding in the rear seat -with his foot braced against a
foot rest. The astragulus was apparently driven directly
against the lower, articulating surface of the tibia. The
skin remained unbroken. The patient was brought in
for treatment ten days after the injury, following which
there had been no attempt to reduce the fracture. Un-

Conclusion

The most severe fractures of the ankle may be
treated with satisfactory results by combined
manipulation and traction in which alignment of
the fractured fragments is maintained by incor-
poration of the traction pins in an adequate plas- |
ter cast. j

No ill effects have been observed by keeping
the knee flexed or the foot out of neutral posi- r
tion during the first few weeks of treatment. J

Satisfactory reduction is possible and may be
maintained without the use of a third traction
pin through the metatarsals for a forward pull
on the foot. Traction in the long axis of the |
leg with variation in the position of the foot |
seems to accomplish in ankle fractures what a i
metatarsal traction wire may offer. |

Local anesthesia in many fresh fractures of
the ankle affords complete freedom from pain i|

810

Tour. M.S.M.S.

HYPOTHYROIDISM IN CHILDREN— HILL AND WEBBER

and a great advantage in its use is that the co-
operation of the patient may be had during the
process of reduction. The consciousness of the
patient is very helpful in that his comfort is bet-
ter assured as the cast is applied and immediately
following the procedure. Seldom is it neces-
sary to make alterations later if the patient leaves
the operating room conscious and comfortable.

No ill effects have been observed by allowing
weight bearing on the injured ankle at the end
of three months following the use of a walking
cast.

References

1. Ashhurst, A- P. C., and Bromer, R. S. : Qassification and

mechanism of fractures of the leg bones involving the ankle.
Arch, of Surg., 1922, 4:51-129.

2. Bohler, Loren: The Treatment of Fractures. Baltimore:

William Wood and Company, 1936.

3. Campbell, W. C. : Operative Orthopedics. St. Louis: C. V.

Mosby Co., 1939. . .

4. Carothers, R. G. : Fractures involving the ankle joint.

Surg., Gynec. and Obst., 1941, 72:410-413.

5. Cotton, F. J. : A new type of ankle fracture. Jour. Am.

Med. Assoc., 1915, 64:318-321.

6. Cotton, F. J. : Dean Lewis Practice of Surgery, Volume

2, Chapter 4. Hagerstown, Maryland. W. F. Prior Com-
pany, Inc., 1940.

7. Cotton, F. J., and Berg, R. : New England Journal of

Medicine, 1929, 210:753.

8. Estes, W. L. : Textbook of Surgery by Frederick Christo-
pher. Philadelphia: W. B. Saunders Co., 1936.

9. Henderson, M. S., and Stuck, W. G. : Fractures of the

ankle, recent and old. J. Bone and Joint Surg., 1935, .15 :882
888.

10. Key, J. A., and Conwell, H. E. : The Management of Frac-
tures, Dislocations and Sprains. St. Louis : C. V. Mosby Co.,
1934.

11. Lounsberry, B. F., and Metz, A. R._: Lipping fractures of
the lower articular end of the tibia. Arch. Surg., 1922,
5:678.

12. Nelson, M. C., and Jensen, N. K. : The treatment of tri-
malleolar fractures of the ankle. Surg., Gynec, and Obst,,
1940, 71:509.

^=|V|SMS_ '

WAYNE SPEECH CLINIC ADDS NEW EQUIPMENT

Wayne University’s speech-correction clinic will be
equipped this year with one of the newest instruments
known in its field: a new type of electro-kymograph,
for measuring and recording breathing patterns.

The device, the only one of its kind in Detroit, was
donated to the university last year by Beta Sigma
Phi Fellowship, a social-scientific group of persons
holding graduate degrees from Wa3me.

The speech-correction clinic, located at 4735 Cass,
near Hancock, offers a special class for adult stut-
terers, which meets Mondays and Thursdays at 7 :00
p.m. There is also a children’s clinic, for help in every
type of speech difficulty, on Saturdays at 9:00 a.m,
TTie class for adults is available without credit at
the usual university class fee ; the children’s program,
similar to that in which 60 youngsters were treated
regularly last year, is available at nominal fees. The
work is directed by Prof. Eugene Hahn, authority
on the treatment of speech difficulties.

The clinic offers academic laboratory experience to
Wayne students training to be teachers of speech cor-
rection, and also functions in improving the speech
of the university students themselves.

The Wayne program functions in cooperation with
the speech correction program in the Detroit public
schools, which is supervised by Miss Hildred Gross.
Most of the cases in the schools are cared for in
the 150 centers maintained by the Board of Education
in various school buildings.

October, 1941

Hypothyroidism in Children

A Review of Masked Symptoms and
Evaluation of Response to Thyroid
Treatment

By A. Morgan Hill, M.D., and
Jerome E. Webber, M.D.

Grand Rapids, Michigan

A. M. Hill, M.D.

M.D., University of Vermont. 1926. Mem-
of Pediatrics. Licentiate Board
of Pedi^rics. Member, Michigan State
Medical Society.

J. E. Webber, M.D.

.^omestown College, North Dakota.

1931. M.D., University of Michigan, 1935.

Member, Michigan State Medical Society.

■ Considerable literature has accumulated on

hypothyroidism in general but it seems that a
scarcity exists in pediatric writings, especially
concerning mild or borderline types, and it is in
some measure the reason for this report on a
number of interesting observations made upon
forty-one patients between the ages of nine
months and fourteen years.

Among the recent authors interested in the
subject are: Shelton;’’’® Topper Cattell;®

Dorff;^ Brown and associates;^ Wilkins \Yat-
kins and Rose.®

Dorff^ appears to have coined the term ‘'masked
hypothyroidism ’ as a description for his cases
“since the symptoms are misleading and often go
unrecognized unless properly studied and in-
terpreted.”

Rose® wrote that “the term ‘paradoxical
hypothyroidism’ is applicable to a group of pa-
tients in whom thyroid deficiency produces an
almost complete reversal of the classic picture.
They are nervous and irritable, undernourished
and sometimes complain of palpitation and tachy-
cardia . . . their only characteristic symptoms are
apt to be fatigability and intolerance to cold,
yet they respond promptly as a rule to desiccated
thyroid.”

We are reporting observations made upon a
group of patients who show disturbances which
may well be metabolic disorders closely related
to hypothyroidism. Because of the lack of a
better explanation of the etiology, as well as evi-
dence of satisfactory response to thyroid sub-
stance in the majority of cases, we believe the
diagnosis of “masked hypothyroidism” can be
applied to most of this group.

811

HYPOTHYROIDISM IN CHILDREN— HILL AND WEBBER

I

Because retardation in carpal bone develop-
ment and a low basal metabolic rate are agreed
upon by most writers on the subject as labora-
tory evidence of hypothyroidism, we have used
these criteria as aids in classifying our cases.
All of the children have had either one or both
examinations included in their case studies. The
examination of x-rays of the bones as well as a
complete physical examination seems sufficient
to rule out other causes of bony retardation as
mentioned by Dorff,^ i.e., “rickets, mongolism,
celiac disease, congenital syphilis, et cetera.” It
is also felt that other causes for hypometabolic
states discussed by Watkins^^ can be ruled out.

Among the total number (forty-one) of chil-
dren, twenty-seven were male ; fourteen were fe-
male. A definite family history of thyroid dis-
turbances was obtained in twelve cases. There
were four families in which two siblings showed
similar symptoms. Twenty-eight of the children
were of school age.

Of the twenty-five children who had x-ray
examinations for carpal development, twenty-two
showed definite delay in osseous growth of more
than six months when compared to the standards
published by Wingate Todd.® Three children
showed development considered normal or with
less than six months’ retardation. One patient in
the latter group had a metabolic rate of minus
twenty-six. The other two patients in addition
to having symptoms and findings similar to the
group described below, gave a history of their
mothers having low metabolism rates and both
were taking thyroid medication while we were
making these observations upon their offsprings.
It may be supposed that if our diagnosis is cor-
rect, the onset of hypothyroid symptoms has
been so recent that no delay was demonstrable at
present.

Of the seventeen patients who were consid-
ered old enough for satisfactory basal metabolism
tests, fifteen showed low readings ranging
from minus seventeen to minus thirty-six. The
other two children were found to have a minus
two and a minus nine rate respectively.

A review of the histories showed that the most
prevalent complaint was frequent upper respira-
tory infection. Twenty-two are in this group.
Most of the children had been on the usual vita-
min mixtures and iron tonics. Many had had so-
called “cold vaccines” and ultraviolet light treat-
ments. About half of these children had already

been subjected to removal of tonsil and adenoid
tissue without any relief from recurrent upper
respiratory bouts. The parents of the remaining
number wanted advice on tonsillectomy, and it
was for this reason that we were asked to see
the patients.

An interesting group of findings in the nose
were either observed at the time of examina-
tion or symptoms originating in the nose were
complained of by the parents or children in
seventeen cases. So far as we know, a similar
reference to these findings does not appear in
pediatric literature, although certain internists
and otolaryngologists have described mucous
membrane pathology in hypometabolic states.
Lee,® in 1925, wrote of the relationship of
vasomotor rhinitis and hypothyroidism. More
recently, in 1936, Bryant^ called attention to
the tendency in metabolic disturbances of in-
fections such as repeated colds, and made a
plea for consideration of hypothyroidism in
cases which did not respond to ordinary
therapeutic efforts. The membranes of the •
turbinates viewed from the anterior nares,
showed a pale, waxy, boggy appearance unless
there was a superimposed infection, in which ^
case the boggy turbinates were red and '
showed marked capillary injection. There of- *
ten was an excessive thin mucoid discharge ,
similar to that seen in an allergic rhinitis. It !
seemed to us that the discharge in these cases
was thinner than in the case of uncomplicated j
cillergy, although in making a differential diag- ^
nosis many times repeated nasal smears were ;
checked and it was not until several smears;
were found to be negative for eosinophilia that
we could be sure that an allergic membrane
was not being observed. As a result of the
marked swelling of the nasal mucosa, many ofi
these patients complained bitterly of nasal ob-
struction and often sleeping, studying and
physical activities were necessarily curtailed.
In some of these children, pale edematous
membranes extended into the pharynx and a
few had a boggy appearing uvula. Although
four of the children showing the above symp-
toms were known to have a seasonal pollinosis,
these mucous membrane findings and repeated
nasal smears were made during the winter!
months when the known irritants had ceased?
to exist. i

812

Jour. M.S.M.S.

HYPOTHYROIDISM IN CHILDREN— HILL AND WEBBER

Twenty of the children showed hyperactivity
on examination or were described by parents and
teachers as restless, fidgety children. Excessive
activity is not a symptom commonly recalled to
mind in hypothyroid individuals. Quite the re-
verse is true. We are used to associating apathy
and sluggish reactions with hypothyroidism. In
Dorff’s^ report which we mentioned previously,
are several cases which were restless and unstable
and appear to be comparable to the animation
exhibited in part of our group.

A group of twelve patients who showed hyper-
activity also presented lack of attention, anorexia,
small stature, nervousness, simian-like behavior,
and irritability ; and resemble the group described
by Rose® as examples of “paradoxical hypothy-
roidism.” This term certainly is an apt one, for
these little individuals suggest “hyper” rather than
“hypothyroidism.”

Shortness of stature was a significant finding
in eleven subjects.

Obesity was present in eight patients, and was
treated by thyroid substance as well as a twelve
or fifteen hundred calorie diet in the more ex-
treme cases.

Slowness in school was an important complaint
in eight children.

Irritability and chronic fatigue each were
found as noteworthy complaints in eight records.

Hypogenitalia was present in five male chil-
dren and was accompanied by undescended testes
in two instances.

Five patients showed a tendency to a persistent
anemia of a hypochromic type.

Constipation was an important complaint in
two histories.

Results of Therapy

The results of therapy were studied and the
progress of each case was summarized and seems
best expressed in degrees of improvement ob-
served as indicated below :

No. Cases

Marked improvement of major complaints 21

Moderate improvement of major complaints 9

Slight improvement of major complaints 8

No improvement of major complaints 2

Insufficient time elapsed to make a report 1

Discussion

The frequence of repeated upper respiratory
infection as a complaint and the large proportion

of children in this group who complained of
nasal obstruction or who showed boggy, waxy,
turbinates, brings out the point discussed by
Bryant^ and already alluded to earlier in this
paper, that patients who, after adequate vitamin
therapy, iron medication, and improved local as
well as general hygiene, still are having repeated
symptoms of disturbed respiratory tract mem-
branes should be considered as possible hypo-
metabolic or hypothyroid patients and should be
investigated accordingly. From our experience
we feel that some improvement will be obtained
in many, although we readily admit that this will
not be true in every stubborn case, as thyroid
substance is not a panacea and the cases must be
carefully studied and classified. Fourteen of the
twenty-two children who had chronic respiratory
infections as a chief complaint showed marked
improvement and eleven of the children who
showed the turbinate mucous membrane changes,
exhibited satisfactory improvement while under
treatment.

Bryant^ mentioned that other chronic infec-
tions which persist in spite of the usual or ac-
cepted treatment should be considered as pos-
sible hypometabolic disturbances. We feel that
a few cases under our observation bear this out.
Three of the children in this report had repeated
styes which persisted although all common means
of preventive treatment were used. After the
children were found to be hypometabolic prob-
lems and treated with desiccated thyroid, the lids
became more resistant to infection and all three
have been without the appearance of new styes
for several months. Another example is the case
of a girl of two and a half years who suffered
from recurrent pyelitis and bouts of high .fever
over a period of six months in spite of every
effort of two pediatricians and a urologist to keep
the urinary tract free from infection. She was
finally examined for possible metabolic disease
and was found to show marked delay in carpal
development and subsequently was given desic-
cated thyroid and has remained free from fever
and the urinary tract free from pus and demon-
strable bacteria for several months.

About half of the children showing hyperac-
tivity as a chief complaint were definitely im-
proved and appeared less restless.

One-half of the children in the smaller group
who showed lack of attention, anorexia, small

October, 1941

813

PSEUDOHYPERTROPHIC MUSCULAR DYSTROPHY— BRANCH

Stature, nervousness and irritability in addition
to hyperactivity and which we have grouped as
examples of “paradoxical hypothyrodism,”
showed marked improvement while under thyroid
medication.

Those children who showed short stature,
obesity, slowness in school, irritability, fatigue,
hyj)ogenitalism; anemia and constipation were
found to respond to the medication in sufficient
numbers to please the parents and to encourage
us to study children showing similar complaints
with a certain degree of optimism.

The accompanying table indicates the amount
of improvement noted in each important clinical
finding or complaint.

Number of Cases Showing Degrees
of Improvement

Clinical Findings

Marked

Mod-

erate

Slight

None

No

Report*

Repeated U.R.I.

14

6

0

2

0

Dry hair and skin

6

5

2

3

1

Nose symptoms

11

5

0

1

1

Hyperactivity

10

10

0

0

0

Paradoxical

hypothyroidism

6

4

1

0

1

Short stature

6

2

0

0

3

Obesity

3

2

3

0

0

Slowness in school

3

1

3

1

0

Irritability

5

2

0

0

0

Fatigue

5

1

0

1

1

Hypogenitalia

3

2

0

0

0

Anemia

5

0

0

0

0

Constipation

I 1

2

0

0

0

0

•Insufficient time elapsed to judge.

Summary and Conclusions

1. Children who show extraordinary resist-
ance to the usual management for prevention of
repeated upper respiratory and other chronic
infections should be studied for possible metabolic

disorders.

2. Children who show extreme irritability,
restlessness, hyperactivity, anorexia and small
stature may be suffering from so-called “para-
doxical hypothyroidism” and should be studied
with this in mind.

3. The more common findings in hypothyroid
cases such as stunted growth, obesity, slowness
in school, irritability, fatigue, anemia, and con-
stipation respond to specific treatment in the ma-
jority of cases in about the same proportion as
the less commonly recognized findings in the
borderline or “masked” cases.

4. We hope that this report will stimulate
others to prove or disprove our impressions.

References

1. Brown, A. W., Bronstein, I. P., and Kraine, Ruth: Am.
Jour. Dis. Child., 57:517, 1939.

2. Bryant, Ben L. : Ann. of Otol., Rhin., and Laryng., 45:
1060, 1936.

3. Cattell, Richard B.: West. Jour. Surg., 41:516, 1933.

4. Dorff, George B. : Jour. Pediatrics, 6:788, 1935.

5. Lee, R. I.: Medical Clinics of North America, 8:1705, 1925.

6. Rose, Edward: Pennsylvania Med. Jour., 42:752, 1939.

7. Shelton, E. Kost: Endocrinology, 15:297. 1931.

8. Shelton, E. Kost: Endocrinology, 17:657, 1933.

9. Todd, T, Wingate: Atlas of Skeletal Maturation. St. Louis:
C. V. Moshv Co . 10.17

10. Topper, Anne: Am. Jour. Dis. Child., 41:1289, 1931.

11. Watkins, R. M.: Ohio State Med. Jour., 35:171, 1939.

12. Wilkins, L. : Delaware State Med. Jour., 11:133, 1939.

=fv^SMS

Progressive Fsendohypertrophic
Muscular Dystrophy*

A New Regime of Treatment

By Hira E. Branch, M.D.
Flint, Michigan

Hira E. Branch, M.D.

M.D., University of Michigan Medical
School, 1932. JDiplomate, the American Board
of Orthopcedic Surgery; Member, American
Academy of Orthopcedic Surgeons, Clinical
Orthopcedic Society, Detroit Academy of Sur-
gery, Michigan State Medical Society.

“ The second sentence of the American Decla-
ration of Independence begins with this state-
ment, “We hold these truths to be self-evident —
that all men are created equal.” This statement is
refuted by many pseudohypertrophic muscular
dystrophy individuals. They are not created
equal. They are composed of inferior materials
and are commonly begot by inferior individuals.
The disorder is always based on heredity. The
hereditary element has been carefully worked
out by Drs. Kostakow and Bodarive at the Medi-
cal Clinic of Bonn University. Pseudohyper-
trophic muscular dystrophy is divided into two
types ; the infantile, noticed at the age the in-

*Presented before the American Medical Association, New
York, 1940.

Jour. M.S.M.S.

814

PSEUDOHYPERTROPHIC MUSCULAR DYSTROPHY— BRANCH

dividual should start walking, and the juvenile,
noticed later in childhood after a period of years
when the individual appeared to be normal.

The infantile type of dystrophic muscle ap-
pears waterlogged, the individual fibers are de-
generated, and fibrous tissue is profuse between
the fibers. In fact the moisture content® of these
degenerated muscle fibers is much higher than
normal. This infantile type of muscle is pale and
is not vascular on section. Thus we expect all
the muscle constituents to be decreased in
amount. That is just what we find. The mois-
ture content is increased but the creatin, magne-
sium and myoglobin are markedly decreased. In
fact there was no magnesium in the cases of the
infantile type of dystrophy that we biopsied and
tested. The magnesium is thought to be very
ifnportant and I will discuss that later.

The juvenile type is different in that the muscle
fibers appear more nearly normal as regards the

son we should find a better content of creatin,
magnesium and myoglobin in the juvenile type

Fig. 1. G. N. — A hopeless
untreated case of pseudohy-
pertro,phic progressive muscu-
lar dystrophy. i

Fig. 2. (from left to right) S. P., J. L.,
H. G. All are dystrophic patients. Notice
similarity of appearance even though the
nationality varies.

Fig. 3. (from left to ri^ht) S. P., J. L.,
H. G. Lateral view of children in Figure 2.
Notice increased lordosis and prominent ab-
domens. Contractures of H. G.’s feet have
been corrected by stretching and casts ap-
plied to hold the correction.

pigment, size of the fiber and moisture content.
However, there is a definite degenerative change
present, there is a fat infiltration between the
fibers rather than a fibrous infiltration, and there
are fewer individual muscle fibers. For this rea-

than in the infantile, and I believe most workers
find this to be so.

The above introductory remarks are made to
emphasize the point that these unfortunates have
not been created equal and are inferior. The

October, 1941

815

PSEUDOHYPERTROPHIC MUSCULAR DYSTROPHY— BRANCH

musculature is inferior as the above proves. The
mentality is inferior as has been shown by men-
tal tests in every one of my cases.

Fig. 4. H. L. (left) showed gradual improvement but re-
gressed somewhat after treatment was stopped in June, 1939.

Fig. 5. A. V. (right) plainly shows a low mental age. Con-
tractures shown at start of treatment were corrected only to re-
cur during a long illness due to bilateral ear and mastoid in-
fections.

Previous Methods of Treatment

There have been many methods of treatment
for pseudohypertrophic progressive muscular
dystrophy. They have all failed to cure. They
were doomed to failure from the start for no one
should expect to make normal muscle where
there is no normal muscle. The object of treat-
ment is to take the inferior musculature of the
dystrophic individual, and make available to this
muscular system the substances necessary for
the efficient functioning of that system. In ad-
dition to having the substances available, there
must be given something that will make possible
the utilization of these substances by the muscles.

The glycine treatment has been used extensive-
ly. It has not benefited the dystrophy patients
treated at the Children’s Hospital of Michigan.
Other workers and clinics have not found glycine
beneficial in pseudohypertrophic muscular dys-
trophy. The glycine treatment is based on a
false premise. It is based on the assumption that

feeding glycine results in an increase in the
creatin excretion in the urine, the mechanism of
which causes a beneficial effect upon the muscles.
It is true that feeding glycine causes an increase
of creatin in the urine but we do not want this.
We want to increase the creatinin excretion, not
the creatin. The administration of glycine ex-
erted little influence on the creatinin excretion.
In general,^ the greater the deviation of creatinin
excretion below normal, the greater is the pa-
tient’s disability. Thus although the glycine
treatment increased the creatin excretion it had
little or no beneficial effect upon the creatinin
excretion, or the dystrophic individual.

Further convincing proof of the glycine false
premise is easily seen in the following table.

This table is postulated on the basis of the work
of P. Eggleton, G. P. Eggleton and Lundsgaard,
as epitomized by A. V. Hill ; The Revolution in
Muscle Physiology (Physiol. Rev., 12;S6 [Jan.]
1932).

Carbohydrates Amido-acids

Glycogen Creatin plus Phosphates

Lactacidogen Phosphagen

Lactic Acid

During muscular contraction
phosphagen is split into creatin and
a phosphate by which energy for
contraction is set free. After
Amount proportion- contraction the lactic acid appears,

ate to amount of phosphagen is restored. (Crea-

muscular energy tinin, one of the by-products, is

developed excreted.)

The accompanying table shows that creatin is
necessary to the normal functioning of muscle.
Creatin is present in the urine of dystrophic in-
dividuals to an extent much greater than normal
while creatinin is commonly less than normal.
Glycine treatment increases the creatin excretion
but not the creatinin. This is not a beneficial ef-
fect, for there already is too much creatinuria.
Therefore, in dystrophies the creatin does not
get into the muscle or the muscle is unable to
utilize it. What is needed then is something that
will make the creatin in the body available so
that it may be utilized by the muscle and ac-
cordingly increase the amount of creatinin ex-
creted. If either the creatinin excretion alone or

816

Tour. M.S.M.S.

PSEUDOHYPERTROPHIC MUSCULAR DYSTROPHY— BRANCH

both the creatinin and creatin excretions be in- wish to present my rationale of treatment, a few
creased then it should indicate an improvement case reports, charts and impressions as a pre-
in the progressive muscular dystrophy indi- liminary report so that other workers may prove
viduals, or disprove the value of this regime.

6.P 1937

— — — — CJ — CJCM — CM

Chart 1. Urinary creatinin and creatin excretion of an
advanced case of pseudohypertrophic progressive muscular
dystrophy. There is a distinct rise in the creatin output which
indicates an improvement in the individual.

Development of a New Regime

In the development of a new regime of treat-
ment there are certain facts that arc known
about progressive muscular dystrophy that are
listed below:

1. The outstanding one is the increase of creatin in
the urinte.

2. The gradual replacement of the degenerating mus-
cles by infiltration of fat.

3. The marked decrease to total absence of magne-
sium in the muscle.

4. The decrease of myoglobin in the muscle.

5. The disease tends to arrest as the individual
matures.

There are other factors in addition to those
listed but their importance in regard to treatment
is not striking. The disconcerting factors are : the
disease is hereditary, the musculature is infe-
rior, the mentality is inferior. Therefore a cure
is not to be hoped for. However, the pathetic
picture of these nice looking, healthy appearing
but hopelessly weakened children coming in to
the clinic year after year caused me to attempt
a regime which might arrest their disease early. I

Chart 2. Urinary creatinin and creatin output of an ad-
vanced case of pseudohypertrophic progressive muscular dys-
trophy. The creatinin excretion maintained a high level through-
out the experiment and was little influenced by treatment.

Rationale

I now wish to take individually the known
facts listed above and rationalize from them
the regime which has given encouragement in
this disease.

1. Creatin is materially increased in the urine
in pseudohypertrophic muscular dystrophy, dur-
ing childhood up to ten or fifteen years of age,
and in the adult during certain physiologic proc-
esses such as lactation, menstruation, or in a va-
riety of pathological processes such as fever,
starvation, severe diabetes or other conditions
associated with deprivation of carbohydrates.
Nutritional creatinuria is easy to correct by reg-
ulation of the diet. In fever the creatinuria
clears when the temperature remains at normal.
In normal adult females there is creatinuria dur-
ing menstruation and lactation but not at other
times. There must be some substance that in-
hibits the creatin excretion normally or that sets
it free during menstruation and lacfation. What
might it be other than female sex hormone? At
any rate if female sex hormone would prevent
menstruation, and it will, it might influence crea-
tin in the body so that it could be utilized instead

October, 1941

817

PSEUDOHYPERTROPHIC MUSCULAR DYSTROPHY— BRANCH

of excreted. If creatin was utilized then creatinin
excretion should be increased in amount. Thus
female sex hormone was used in two hopeless
patients, first in an effort to work out the dosage

lar in that on “cholesterol” fatty liver the main
effect is to decrease substantially the glycerine
content of the livers and to a lesser extent the
cholesteryl ester formation. Thus it seemed that

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Chart 3. Marked rise in creatinen excretion coinciding with a remarkable clinical im-
provement.

and second to see if the creatin-creatinin excre-
tion would be influenced. (See Charts 1 and 2.)

2. The replacement of the muscles by fat is a
disturbing fact and there is nothing similar in
normal individuals. Perhaps this is due to a dis-
turbance in the metabolism of fat. A search was
made for a drug that would influence fat metab-
olism.

It is known that the presence of choline in the
diet of rats favors the normal distribution of fat®
between the liver and the body depots, and pre-
vents the failure of certain functions of the liver.

Choline has been shown to exercise prophylactic
and curative effects^ on the “fat” fatty liver and
the “cholesterol” fatty liver of rats produced un-
der a variety of experimental conditions. Diets
deficient in choline and other lipotrophic factors®
produce an accumulation of fat in the livers of
white rats. In these rats the administrations of
choline always prevent the deposition of liver
fat, and under certain conditions it appears to
act favorably on the gain in weight of the ani-
mals. The results of experiments suggest that
choline may improve the “general condition” of
the rats. Homocholine® ( trimethyl-y-hydroxy-
propyl-ammonium hydroxide) is stated to be
more effective in controlling the percentage of
fat in livers than is choline. The action is simi-

if these drugs influenced fat metabolism in rats
they might in humans. Homocholine was not
readily available but choline hydrochloride and
choline chloride was. Accordingly choline was
fed to the pseudohypertrophic muscular dystro-
phy patients in the hope it might control fat dis-
tribution, influence favorably fat metabolism, and
improve them “generally.”

3. The role of magnesium is largely hypo-
thetical. Benjamin Cassen, Ph.D., formerly of
Harper Hospital, Detroit, and now connected
with Westinghouse Research Department of
Pittsburgh, first drew my attention to this inter-
esting and important element. Magnesium is de-
tected in muscle tissue by means of the spectro-
graph. In the infantile type of pseudohyper-
trophic muscular dystrophy there were no mag-
nesium bands, in the juvenile type the bands
were present and normal in amount.

The role of magnesium has not been definitely
proved. However a great deal of circumstantial
evidence^ seems to indicate that cells and mus-
cles, in particular, contain an organo-magnesium
compound of non-proteinic nature in which the
magnesium is in nonionic form. This compound
is a catalyst for the final stage of the combustion
of carbohydrate to carbon dioxide and water. It
is known that catalysts can catalyze a reaction in

J L 1938

URINE

CREATININE ■

818

Tour. M.S.M.S

PSEUDOHYPERTROPHIC MUSCULAR DYSTROPHY— BRANCH

either direction. The inverse reaction, the syn-
thesis of carbohydrates from water and carbon
dioxide, is catalyzed by a magnesium containing
nonionic substance, chlorophyll.

fibrous tissue that the muscle fibers seem to have
little myoglobin and undoubtedly could not use it
satisfactorily if they had lots of it. In the juve-
nile type of pseudohypertrophic dystrophy the

Chart 4. A decided rise in creatinin excretion is shown. This coincided
with marked clinical improvement in the pseudohypertrophic dystrophy patient.
He now runs, plays baseball and gets up without “climbing.”

The magnesium content of the infantile type of
pseudohypertrophic dystrophy muscles is nil and
the moisture content is above normal. It is an
easy step to give a diet containing magnesium in
the hope this condition might be remedied. Cows
milk contains magnesium in fair amounts, goat
milk even more so. Camel milk has an even
greater magnesium content though it is not avail-
able but cow and goat milk is. Thus the dystro-
phies were given abundant cow’s milk and some
were given goat’s milk in the hope the magne-
sium might be utilized in the muscle cells.

4. Myoglobin'’' is less in the dystrophic muscles
than in normal muscles. It is probably less in
the infantile type of dystrophic muscles than the
juvenile type. I feel this is so because of the
decreased muscle tissue present in the infantile
type and the increase of fibrous tissue present. I
have no definite proof of this. However, the
blood of dystrophy patients is about normal and
there is an abundant source of materials for the
formation of myoglobin in the body. It should
not be necessary to add to this source other than
to prevent anemia in these patients. In the infantile
type of pseudohypertrophic dystrophy the muscu-
lar system is so waterlogged and infiltrated with

October, 1941

muscle appears to have about normal myoglobin
if only the muscle fibers are examined and not the
fat. Thus no attempt was made to furnish myo-
globin other than to keep the blood in as normal
a state as possible.

5. The fact that the progression of the disease
is less as the dystrophic individual matures is in-
triguing. Why not make these children mature as
fast as possible in the hope the disease may be-
come quiescent? I suggest that an extract of
anterior pituitary glands be given. This might
bring maturity faster, but even though it did not
it would enhance the value of the female sex hor-
mone. It was not used in these experiments as
it might have obscured the results obtained by
the female sex hormone.

Resume of the New Regime

1. Female sex hormone is given in an effort
to favorably influence the creatin-creatinin
utilization and excretion.

2. Choline, in the form of the hydrochloric
or the chloride, is fed in an effort to favorably
influence the metabolism and deposition of fat.

3. An attempt to make magnesium available
in the body zmd muscular system is made by

819

PSEUDOHYPERTROPHIC MUSCULAR DYSTROPHY— BRANCH

giviriig abundant quantities of cow’s milk or
goat’s milk.

4. Anemia is prevented.

5. An extract of anterior pituitary glands

surgery. Stretching a dystrophic muscular con-
traction is similar to bending a lead pipe — there
is a rubbery resistance at first which gives way
suddenly after so much correction (or bending)

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Chart 5. Creatinin output remains above normal throughout this regime with definite rises
tar above normal The boy improved. He now touches toes and arises without ‘‘climbing,” runs
about and can be lifted by his shoulder girdles.

might be given in an attempt to hasten the
maturity of the patients, and enhance the effect
of the female sex hormone.

6. In addition to the above, general setting-
up exercises, physiotherapy, fresh air and sun-
shine is administered.

Contractures are overcome by gentle manipu-
lation and stretching under an anesthetic — not

has been obtained. Surgical lengthening of these
dystrophic muscular contractures only makes the
muscle weaker. All the patients are given corsets
to splint the weakened abdominal and back
muscles.

Case Reports

Case 1. — G. P., born October, 1927. Convulsion at
one week and again while teething. Walked at eighteen
months but weak and shaky. Father a drunkard. Moth-

820

PSEUDOHYPERTROPHIC MUSCULAR DYSTROPHY— BRANCH

er and one sibling living and well. One sibling with
pseudohypertrophic progressive muscular dystrophy.
Patient a hopeless case, used to observe effect of re-
I gime. April 20, 1937, started on 25 rat units female
' sex hormone daily, increased to 50 units daily five days
each week on April 27.

advice, stating he was so near normal he needed no
more treatment.

Case 4. — S. P., born October, 1930. Walked at two
years with difficulty and on toes. Father dead (pneu-
monia). Mother and seven siblings well. February 23,

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Chart 6. Creatinin excretion is definitely above normal. Clinically the boy gradually im-
proved. He regressed slightly after the treatment was stopped for the summer months.

Chart 7. Urinary creatinin and creatin output of a refractive case. There is little change in
the creatinin excretion. No clinical improvement was seen.

i Cax^e 2. — J. P., born September, 1926, brother of G.

I P. Difficulty walking since eighteen months. Hopeless
I case, used to observe effect of regime. April 20, 1937,
started on 25 rate units female sex hormone daily

' and increased to 50 units daily five times each week, on
i April 27.

Case 3. — ^J. L., born May, 1931. Weakness noticed in
September, 1937. Mother, father and two siblings liv-
i ing and well. February 3, 1938, started on choline gr.

! XV daily. No ill effects. February 8, choline gr. XV

j T.I.D. and 50 rat units female sex hormone daily

: five days each week, was started. Clinical improve-
ment marked. Muscular strength so increased that

; parents took child home in December, 1938, against

i October, 1941

1938, started on choline gr. XV T.I.D. and 50 rat units
female sex hormone daily five times each week. Mus-
cular strength increased enormously. Touches toes, gets
up normally, can be lifted by shoulder girdles. Walks
and runs but has weak abdominals and mild “Aider-
man’s” gait.

Case 5. — H. G., born October, 1931. Weakness, stum-
bling since starting to walk. Contractures present.
Mother, father and three siblings well. September 21,
1937, started on 50 rat units female sex hormone daily
five times each week. January 18, 1938, tonsillectomy
and adenoidectomy. June 29, 1938, treatment stopped.
September 8, 1938, female sex hormone again started
and choline gr. XV twice daily started. March 22, 1938,

821

PSEUDOHYPERTROPHIC MUSCULAR DYSTROPHY— BRANCH

bed ridden for three weeks with scarlet fever. Child
improved definitely, contractures eliminated. Touches
toes and arises without climbing. Can be lifted by
shoulder girdle.

Chart 8. A young but severe case of dystrophy. The boy
definitely improved clinically. The creatinin excretion was
maintained about normal.

Case 6. — H. L., born July, 1931. Increasing weakness
since starting to walk. Parents and one sibling well.
Sept. 20, 1938, started on choline gr. XV T.I.D. and 50
rat units female sex hormone daily five times each
week. Examination June, 1939, showed considerable im-
provement, runs and walks, can be lifted by shoulders,
can touch toes and arise without climbing.

Case 7. — A. V., born September, 1930, unable to walk
or stand alone since birth. Contracture legs and hips
(see picture). Mentality low. Parents well. September
15, 1938, started on choline gr. XV T.I.D. and 50 rat
units female sex hormone daily five times each week.
Oct. 25 could walk with aid of one finger to help sup-
port him. January 29, 1939, acute otitis media bilateral.
Regime discontinued. February 2, mastoidectomy.
March 7, tonsillectomy and adenoidectomy. January 9,
1939, placed on regime of medication. Contractures
recurred during his severe illness, patient refuses to sit
or walk. Sent home for summer with crutches. Result
a failure.

Case 8. — F. G., born Dec., 1932. Weakness since
starting to walk. Mother and father well. One brother
dead, suffered from muscular dystrophy. Patient on
admission to hospital unable to walk up or down stairs,
cried when placed on feet and yelled he could not
walk. March 14, 1939, started on choline gr. XV T.I.D.
and 50 rat units female sex hormone daily five days
each week. Examination June, 1939, showed marked im-
provement clinically. Runs, walks well. Touches toes
and arises without climbing. Can be lifted by shoulder
girdle.

Results

Eight patients were used in this experimental
work. G. P. and J. P. were hopeless cases used

only to observe the effect of the female sex hor-
mone. Chart 1 reveals a definite increase in the
creatinin excretion after treatment was started
on April 20. Chart 2 reveals the creatinin ex-
cretion to be maintained at normal with occa-
sional elevations above normal.

The next six cases were placed on the regime
of treatment in an effort to improve their gen-
eral condition and arrest the progression. Three
of these patients had a marked increase in the
muscular power, two patients had a definite im- ,
provement but not approaching normal. One 1
patient (A. V.) had slight improvement at first
then developed bilateral otitis media and mastoid-
itis, and end result was a total failure. The charts
bear out the clinical improvements. Charts 3, 4, |
5 and 6 show definite increase in the creatinin
excretion. Chart 8 maintained a normal creatinin
excretion. Chart 7 shows no influence on the
creatinin excretion as a result of treatment.

Comment

A new regime of treatment for pseudohyper-
trophic progressive muscular dystrophy is offered.
The results over a three-and-a-half-year period '
are so encouraging the regime is presented in this
preliminary report in the hope other workers will
try it, and thus prove or disprove its value.

I wish to express my sincere appreciation to Dr.
F. C. Kidner. Dr. F. E. Curtis and Dr. Charles W.
Peabody of the orthopedic staff of Childrens Hospital
of Michigan for the use of their patients in this study.

I thank the laboratory staff of the Childrens Fund
of Michigan for their aid in the blood and urine
analyses.

I thank Dr. Plinn F. Morse, chief of the Pathology
Department of Harper Hospital, for his aid in the
microscopic pathology.

Bibliography

1. Adams, Mildred and Power, M. H. ; Proc. Staff Meetings
Mayo Clinic, 9:591-599, (July) 1934.

2. Best, C. H., and Channon, H. J. : Biochem. Jour., 29:2651,
(Dec.) 1935.

3. Best, C. H., Mawson, M. Elinor Huntsman, McHenry,
A. W., and Ridout, J. H. : Jour. PJiysiol., 86:315-323, 1936.

4. Cassen, B. : Personal communication.

5. Channon, H. J., Platt, A. P.. and Smith, J. A. B.: Bio-

6. Guettach and Brown: Jour. Biol. Chem., 97:549, 1932.
chem. Jour., 31:736, 1937.

7. Gunther: Arch. Path. Anat. Physiol., 230:146, 1921.

8. Maclean, D. L., Ridout, J. H., and Best, C. H. : Brit.
Jour. Exp. Path., 18:345-354, (Oct.) 1937.

^=Msms_

MILITARY SURGEONS MEETING

The Association of Military Surgeons of the United
States will meet October 29 to November 1 at the
Brown Hotel, Louisville, Ky.

All members of the medical profession are invited
to attend as guests and it is particularly hoped that as
many members of the Medical Defense Committees as
possible will come.

The session concludes with a mass review of Military
Medicine and an inspection of Fort Knox.

822

Jour. M.S.M.S.

SARCOMA OF URINARY BLADDER— KEANE

SarcDma of the Urinary Bladder

With Report of Cose

By William E. Keane, M.D.

Professor of Urology, Wayne University, College
of Medicine

Detroit, Michigan

William E. Keane, M.D.

M.D., Wayne University College of Medi-
cine, 1902. Professor of Urology and Head
of the Department of Urology, Wayne Uni-
versity College of Medicine; Attending Urolo-
gist, Detroit Receiving Hospital; Attending
Urologist, Providence Hospital, Detroit; F. A.

C. S.; Member, the American Urological As-
sociation, Michigan State Medical Society.

■ Sarcoma of the urinary’ bladder is seldom
seen by the urologist and rarely are these
tumors seen early. For that reason the follow-
ing case is reported with its salient features as
to diagnosis and treatment together with an ac-
companying brief review of the literature.

Vesical sarcomas, as a rule, originate in the
sub-mucous and muscular layers of the bladder
wall. They are, therefore, intramural in the
vast majority of cases, but generally become in-
travesical, polypoid, and papillomatous by inva-
sion of the overlying mucosa, which may re-
main intact or ulcerate. Because of their ex-
treme vascularity, they appear dark red to red-
dish blue on cystoscopy. In this connection
Albarran held, that myoma and fibro-myxoma
of the bladder were also malignant tumors and
probably closely allied to myxosarcoma.

Myxomas are very’ malignant and grow with
extreme invasiveness. They occur usually dur-
ing the first decade of life. According to Dom-
ing 24.5 per cent of vesical neoplasms during
the first years of life are myxosarcomas. Char-
acteristically they are soft, smooth, gelatinous
and lobulated. They are composed of richly vas-
cular loose connective tissue covered by squa-
mous epithelium. Metastases are unusual and
are absent in the majority of autopied cases, but
when they do occur the common sites are the
sacral glands, lungs, liver and bones. Herman,®
in describing the clinical features of this new
growth says : “Vesical sarcomas are most fre-
quent before the tenth and after the fiftieth
year.”

Symptoms

Hematuria is usually intermittent, often pro-
fuse and may be the initial symptom. The domi-
nant early clinical feature besides hematuria,
is urinary obstruction associated with pain and
strangury. Since these tumors are intramural
they are rarely seen in what may be considered
an early stage of their development and usu-
ally are far advanced as shown by the symptoms
mentioned above.

Diagnosis

Cystoscopy and cystography will show the neo-
plasm but no characteristic feature will dis-
tinguish it from other neoplasms especially when
there is bleeding from the surface. Biopsy is
essential for a precise diagnosis but it is nec-
essary that the tissue obtained is representative
of the tumor so that there will be no failure to
positively identify it. Bimanual palpation of the
bladder wall sometimes helps to reveal the area
of infiltration.

Case Report

V-18729, aged seventeen, white, female, was ad-
mitted to Detroit Receiving Hospital November 19,
1939. She was apparently perfectly well until about
three and one-half weeks before admission.

History. — At that time, she began having sharp
suprapubic pain at the end of urination. The pain was
not very severe at first but gradually increased in in-
tensity. Five days before admission she first noticed
gross hematuria. This was bright red blood at first
but the next day she passed dark blood and clots.
There were no other urinary complaints. She had
lost no weight and she complained of no anorexia or
fatigue.

Past history was negative except for the usual child-
hood diseases.

Family history revealed that a half-brother died
from pulmonary tuberculosis and a paternal aunt died
from carcinoma of the breast.

Physical Examination. — Physical examination was
entirely negative except for definite tenderness over
the suprapubic area, and the palpation of a hard wal-
nut sized mass in the right superior bladder wall bi-
manually.

Laboratory Examination. — Laboratory urinalysis on
admission revealed specific gravity of 1.015 ; sugar, neg-
ative ; albumin, 4 plus ; microscopic : innumerable red
blood cells. The Kline test was negative. Hemoglobins
were 11.4 gms. Leukocytes 6,750 with 79 per cent
polymorphonuclear neutrophiles and 21 per cent
lymphocytes.

October, 1941

823

SARCOMA OF URINARY BLADDER— KEANE

Course. — The day following admission she was cys-
toscoped and the findings were as follows : Grossly

bloody urine returned after the passage of the scope.
Bladder capacity was 200 cc. with slight discomfort.
On the right superior wall of the bladder well away
from the right ureter was a growth 2.5 cms. in di-
ameter protruding into the bladder cavity. It was
not cauliflower in type but appeared like a cervix
protruding into the bladder. The mucosal covering
of the mass was normal in appearance except for two
small hemoglobic areas from which the recent bleed-
ing had occurred. The remainder of the bladder was
entirely normal in appearance. A biopsy of the
tumor was taken and the smooth surface bled readily.
The pathologic report of the biopsy by Dr. O. A.
Brines revealed that the amount of tissue was too
small for diagnosis. A cystogram was made at the
time of the cystoscopy and showed no infiltrative
lesion of the bladder wall. X-ray examination of the
chest was reported as entirely negative.

Because of the negative first biopsy it was thought
advisable to obtain the second specimen by means
of the resectoscope. A good representative section was
taken after which the area was fulgerized to control
the bleeding. The biopsy section was composed of
slender, spindle shaped neoplastic cells, quite regular
in size, with an orderly arrangement and a very loose
edematous stroma. The biopsy diagnosis was fibroma
or myxofibroma with added statement that sarcoma
could not be ruled out. No muscularis was included
in the biopsy.

Discussion at the Tumor Conference developed
along the line of whether the lesion should be treated
palliatively with fulguration to control bleeding or
whether the portion of bladder wall occupied by the
tumor should be resected. The latter recommendation
was followed.

Pathologic Report. — The microscopic sections rep-
resented a neoplasm composed of very slender long
cells possessing abundant cytoplasm which stained
deeply with eosin. There was intercellular stroma, com-
paratively acellular, slightly basophilic, quite abundant
in places, which was described as myxomatous. This
stroma was quite richly vascularized. The neoplastic
cells exhibited a tendency to form bundles. There
was some irregularity in nuclear size and staining in-
tensity with the formation of a number of giant hyper-
chromatic nuclei. The muscularis of the bladder was
being extensively invaded, destroyed and replaced by
neoplastic tissue. The pathologic diagnosis was leio-
myosarcoma of the bladder wall.

Further Course. — The bleeding ceased and the re-
maining evidence was only the small fibrous area
which could still be palpated bimanually in the blad-
der wall. Because the location was favorable for open
operation and the questionable microscopic diagnosis
of the tumor, it was deemed advisable to resect the
mass by open operation rather than attack it by any
other method. The bladder was opened and with good
exposure the small intramural growth was easily ex-

cised. The tumor seemed to be well localized to the
muscular layer of the bladder wall. The bladder wall
was tightly sutured, a drain placed in the pre-vesical
space and an indwelling urethral catheter inserted.

The postoperative course was uneventful and the
wound healed readily by first intention. She was dis-
charged from the hospital on the sixteenth post-
operative day and forty-two days after her admission.

Cystoscopy one month postoperative revealed a
bladder interior of normal capacity and contour. The
cleanly healed scar was seen with no evidence of re-
currence of the tumor. Another check cystoscopy one
month later revealed a slight nodularity about the
scar without breaking the continuity of the mucosa.
It was felt that this was very suggestive of an early
local recurrence of the tumor. Because of the apparent
invasion of the tumor beyond the excised area and
in spite of the girl’s age, with possibility of resultant
sterilization, it was thought advisable to give her an
intensive course of deep x-ray therapy. The first series
of deep x-ray therapy was begun on Febrary 27, 1940,
and consisted of nineteen consecutive daily treatments,
totaling 3,800 roentgen units, alternating between an-
terior pelvis, including both groins and posterior pel-
vis. A check cystoscopy on March 21, 1940, one
month after the first course of x-ray revealed a de-
crease in the nodularity noted on the previous exami-
nation. The next cystoscopy was on April 21, 1940,
at which time no evidence of the afore-mentioned
nodularity about the scar was noted. The second
series of deep x-ray therapy consisted of 12 treat-
ments, totaling 2,400 roentgen units, given from May
13, 1940, to May 25, 1940. Cystoscopy one month later ^
revealed no evidence of reformation of the tumor.
The third and last series of therapy consisted of ten
treatments, totaling 2,000 roentgen units, given over a
ten day period beginning August 19, 1940. With the
completion of this series she had received a total
of 8,200 roentgen units, given in three series, during
a six months period. The most recent cystoscop}' ten
months after resection of the bladder tumor showed
no evidence of local recurrence and x-ray of the
pelvis and chest are likewise negative.

Acknowledgment and thanks are given to Dr. Donald J.
Jaffar, Junior Attending Urologist, and Dr. Carl Anneberg, Res-
ident in Urology, Detroit Receiving Hospital, for their assistance
in presenting this case.

= [V|SMS

Whisperings of a “strike” in the course of physical
examinations for the Selective Service Boards are
heard in one section of a highly populated county in
Indiana. It seems that the medical examiners, who
are doing their work gratis, expect the paid employes
of the Board to do a bit of the clerical work, thus
minimizing the task of the unpaid physicians. The paid
employes have rebelled, stating that this is the job
of the doctors. Our recommendation is that when
such an occasion arises the medical men walk off the
job and remain away until these suddenly-officious
persons come to their senses. It’s queer how a city,
government or state job goes to one’s head! — The
Journal of the Indiana State Medical Association, Au-
gust, 1941.

824

Jour. M.S.M.S.

To The Future

WITH gratitude, but with a sense of humility I
assume the Presidency of the Michigan State
Medical Society, with thanks to our members for this
high honor. I sincerely request a continuation of the
generous help, interest and teamwork of the member-
ship during my tenure of office.

Particularly from my committee workers, I request
their sustained activity and effort in medical and civic
affairs. The influence and -prestige of the Michigan
State Medical Society rest mainly on the work of its
committee personnel.

Finally, I urge all members to gather into our ranks
eveiy eligible doctor of medicine, for his good and
for the good of the Society. Particularly, all interns
and hospital residents should be invited by active
members to become affiliated, now, with the Michi-
gan State Medical Society. In those counties having
medical schools, the senior students should be urged by
their professors and by the county medical society
officers to attend the society meetings, both county and
state. What Medicine is to be tomorrow depends upon
the moulding of the young medical mind of today.

President, Michigan State Medical Society.

October, 1941

825

-X EDITORIAL x-

THE BEST YET

■ The Seventy-sixth Annual Convention has
passed into the records. The almost universal
opinion expressed is that it was run more
smoothly than any other recent convention.
Splendid arrangements for housing by the Pant-
lind Hotel, the cooperative spirit of the people of
Grand Rapids, the enthusiasm and energy of the
exhibitors, and the lavish entertainment program
formed a perfect background for the unexcelled
array of scientific papers.

Every speaker appeared as scheduled and not
even the usual amount of dissatisfaction was
heard.

The Section meetings were so well attended
that in some of them the available space was filled
to capacity. Special comment was received on
the value to the general practitioner of the papers
which were given in the Sections.

The Discussion Conferences, an innovation of
1941, were enthusiastically enjoyed and provided
a splendid opportunity to correlate the presen-
tations from the General Assembly.

The scientific exhibits included some excep-
tional displays for visual education.

The attendance was eminently satisfactory, al-
though the ultimate hope to have every practicing
member of the Michigan State Medical Society
register at the state convention was not reached.

Comments on the organization activities and
Michigan Medical Service will be found else-
where and it will be noted that they are propor-
tionately satisfactory to the scientific part of
the meeting.

= [V|SMS

MICHIGAN MEDICAL SERVICE

• At a special meeting of the Delegates and
some interested members, held September 15,
1941, the night before the official meeting of the
House of Delegates, several hours were spent in
receiving reports and discussing the various
phases of the Michigan Medical Service.

The meeting which opened with a series of
discordances ended with general satisfaction and
the acknowledgment that despite some apparent
inequalities the program, with a few minor

changes, was desirable and its continuance to be
favored. This same view was reflected the next
day in official meetings of the House of Dele-
gates.

Although a number of resolutions were in-
troduced, only three were accepted by the
House and they were referred to the meeting
of the members of the Corporation. One of
these asked that some investigation and ex-
perimentation be made in issuing and selling
limited liability policies. Another resolution,
which advocated the lowering of income limits >
was discussed in the meeting of the Corpora-
tion with no final action being taken. One in-
teresting sidelight was the clarification of the
oft-raised question as to who had determined
the existing income levels. It was finally
shown that these limits had been set in 1939
by the House of Delegates without recorded
opposition.

The Board of Directors of the Michigan Med-
ical Service met during the MSMS Convention
and steps were taken to begin the investigation
and experimentation in the matter of limited lia-
bility certificates. At the same time authorization
to contract with the General Motors Corporation
and its employes toward the issuance of surgical
contracts to the employes and their families was
voted by the Board. This will provide between
160,000 and 170,000 new but well-seasoned sub-
scribers to the plan. With General Motors plants
in a number of cities in Michigan the benefits
will be greatly extended and a greater degree of
stability attained for Michigan Medical Service.

=t-=[\/^SMS

AN ERROR CORRECTED

■ Information furnished by Wilfrid Haughey

of Battle Creek revealed an error in the Sep- |
tember editorial on President Henry R. Car- 1
stens. It was stated therein that Dr. Carstens was |
the first son to follow in a father’s footsteps as
president of the Michigan State Medical Society
Not only is our present incumbent not the first ■

Jour. M.S.M.S.,

826

EDITORIAL

in Michigan to achieve this distinct honor, but
he is the fourth.

Perhaps this record is unique in medical

I history of the United States! David Inglis,
president of the society in 1905, followed his
father, Richard Inglis, of Detroit who had
been president in 1869. The following year, in
1906, Charles B. Stockwell became president,
his father having been Cyrus M. Stockwell
of Port Huron, the first president of the re-
organized state society, in 1866. Leartus Con-
nor of Detroit was president in 1901 and in
; 1923 his son, Guy L. Conner, succeeded in his
footsteps.

Other interesting information received from
i Dr. Haughey disclosed that Henry O. Hitchcock
of Kalamazoo was president in 1871 and his son,
Charles W. Hitchcock, became secretary from
1890 to 1895. Jerome K. Jerome of Saginaw was
! president in 1867 and was again elected president
S in 1881. Andrew P. Biddle of Detroit is the
only president who ever served two consecutive
terms.

The profession is indeed indebted to these fam-
ilies of medical leaders.

: =[V|SMS

THE NEW DISEASE

American physicians must prepare to cope with a
new disease. It is becoming generally prevalent and
may reach epidemic proportions and severity. It is
contagious, and attacks all without discrimination, in-
cluding those who fill the ranks of the trades and the
professions.

By virtue of their training, their ethics, the nature
and the demands of their profession, doctors are espe-
cially susceptible to the contagion. Until it is better
named, the new disease can be called “War Fever.”
The future effectiveness of American medicine and
the future status of the American doctor will be deter-
mined by the extent to which individual physicians are
successful in immunizing themselves against the hys-
teria which is a symptom of and which always accom-
panies the disease.

The world is at war. One hundred and thirty mil-
lion Americans are very much a part of this world.
1 It is a wholly new kind of war. In times past, material
advantage and territorial gains provided the incentive
for wars of aggression. This is a war of ideological
conquest. Material advantages and territorial gains
are merely incidental to the larger purpose. It is an
all-out warfare, spending lives and treasure on a
scale never before contemplated or even imagined by
; man.

^ In the present situation there are too many uncer-
tainties to enable either the wisest or the best informed
’■ reasonably to predict the extent to which it may be
; necessary to sacrifice the lives and material resources
of this country in order to win this war. It is a
>•' I known fact — and it should be faced — that we are in the
( process of mobilizing all of our energies and utilizing
all of our resources for the accomplishment of this
••‘j purpose.

ii OcrroBER, 1941

It is almost needless to say that no group will be
called upon to make a greater contribution than will
be expected from the medical profession. It is need-
less to say that this contribution will be gladly, cheer-
fully made by American physicians. American doctors
do not expect any special credit for the important
service they are rendering or will be called upon to
render. Their tradition, their training and experience
make this attitude inevitable. Many are already enlisted
for the duration. The rest will be ready when called.

However, the greatest national danger lies in the
possibility of these doctors becoming victims of the
“new disease.” On them rests a new and most vital
responsibility. It is of the utmost importance that these
physicians ever keep in mind that the war itself is one
of ideologies ; that our first obligation and most difficult
task is to preserve the Priceless Heritage of the Ameri-
can People that has set them over and above and apart
from all the other people in the world. It is desirable
to consider carrying the “four freedoms” to all the
people in the world. But — it is essential that we main-
tain our own independence and freedom of action —
“for what shall it profit a man if he shall gain the
whole world and lose his own soul?” It is our task
now to “hold fast that which is good.”

Tomorrow will come the peace. While we unselfishly
and unlimitedly serve, we should make sure that stifling
control of bureaucracy is not permanently establishei
We should take steps to insure the preservation of the
sacred doctor-and-patient relationship, the independence
of the physicians, the continue progress of American
medicine and the safeguarding of the public interest.

Medicine’s planning and administrative agency in
these fields is the National Physicians' Commit-
tee for the Extension of Medical Service,
Pittsfield Building, Chicago, Illinois. It has demon-
strated both its reliability and its effectiveness.
In these times of increasing stress it should have
the allegiance and financial support of every patriotic
practicing physician. If your county association has
not appointed an official committee to cooperate with
N.P.C., it should do so at the next regular meeting.

PAY-YOUR-DOCTOR WEEK

Fourth annual “Pay-Your-Doctor Week” will be
observed this year, November 2 to 8.

Inaugurated in 1938 by California Bank in Los
Angeles, observation of “Pay-Your-Doctor Week”
swiftly spread to. scores of cities throughout the coun-
try and last year virtually achieved nation-wide recog-
nition.

Primary purpose of “Pay-Your-Doctor Week” is to
pay tribute to the members of the healing profession
who quietly but relentlessly continue the battle against
disease and sickness, particularly at this time when
much of the world is engaged in destroying rather
than preserving life.

Recognized also is the fairly widespread tendency
to “let the doctor wait” until all other bills have been
paid.

Sponsors of “Pay-Your-Doctor Week” point out that
the plight of the country doctor who is often paid with
farm products or a share in next year’s crop has been
widely publicized in recent years while little has been
said about the city doctor whose reward for services
rendered all too frequently consists mainly of long
hours of practice and vague promises of payment
sometime in the future.

Because “Pay-Your-Doctor Week” was originated
and is sponsored by the banking profession, the ques-
tion of medical ethics is not involved.

Banks sponsoring the week throughout the country
call attention to the fact that funds are available to
lend for the purpose of paying doctor bills.

827

X- YOU AND YOUR BUSINESS x-

THANKS

The Council of the Michigan State Medical
Society has placed on its minutes a vote of thanks
to all who contributed to the extraordinary suc-
cess of the State Society’s 1941 Annual Meeting.
The Council is grateful to the guest-essayists,
their “ubiquitous hosts,” the officers of the So-
ciety, the chairmen and secretaries of the Gen-
eral Assemblies and of the Sections, the Discus-
sion Conference Leaders, the Monitors of the
Sections and Discussion Conferences, the efficient
Press Relations Committee, the Hospitality Com-
mittee, the Grand Rapids Committee on Ar-
rangements, the Scientific and Technical Ex-
hibitors, the Radio Stations, the newspapers for
many columns, the Grand Rapids Convention
Bureau, our friends who sponsored lectures at the
General Assemblies, the management of the Kent
Country Club, the Kent County Medical So-
ciety, and all who by their active help made
the meeting such an enjoyable and instructive
affair ; not the least, thanks are due to all the
members who by the hundreds left their busy
practices in all parts of the state to visit Grand
Rapids for the 76th Convention of the Michigan
State Medical Society.

Ladies and Gentlemen, thank you again !

rf^SMS

PHYSICIANS MAY SELECT HOSPITALS
FOR AFFLICTED CHILDREN

Section Six of the Afflicted Child Law (Act
283 of the Public Acts of 1939) specifically
states ;

“The Commission may enter an order, direct-
ing that such child be conveyed ... to a hos-
pital in the State selected by the attending
physician, and which has been approved and
designated by the Commission for the care of
Afflicted Children.”

This applies, at the present time, only to
Afflicted Children.

If any attempt is made to take this preroga-
tive away from a physician, he should cite the
above section of the Afflicted Child Law as his
authority and insist upon his rights, provided
the hospital of his choice is approved by the
Commission and is in his locality.

828

MEDICINE OUT OF THE AIR

At the 76th Annual Meeting of the Michigan
State Medical Society, radio played an important
part. Radio Stations WOOD and WLAV of
Grand Rapids cooperated wholeheartedly by giv-
ing freely of their time and facilities. The fol-
lowing talks on matters of scientific and general
interest were presented during the Convention
week: “The Functions of Medicine and the

Michigan State Medical Society,” by Wm. A.
Hyland, M.D., Grand Rapids, September 15;
“What the Doctor’s Wife Means to the Com-
munity,” by R. C. Jamieson, M.D., Detroit,
September 16; “The Value of Postgrad-
uate Medicine to the Public,” by H, H. Cum-
mings, M.D., Ann Arbor, September 17 ; “The
Family Doctor,” by W. H. Huron, M.D., Iron i
Mountain, September 18; and “Michigan Medi- «
cal Service,” by Henry R. Carstens, M.D., De- ,
troit, September 19. I

= [^SMS

MEMBERSHIP MARCHES UPWARD

The membership of the Michigan State Medi-
cal Society, as of September 12, 1941, stood at
4,432 members, the greatest total in the history
of the Society for that date.

The record for the past six years stands as
follows :

1940 1939 1938 1937 1936 1935 I

July 4,401 4,255 3,958 3,757 3,457 3,410

December 31 4,527 4,425 4,205 3,963 3,725 3,653 !

= [V|SMS

PLACEMENT BUREAU

The Placement Bureau of the IMichigan State
Medical Society has been working quietly dur-
ing the past three years but has been doing a
constructive job of finding locations for physi-
cians as well as successfully interesting doctors
in locating where more medical service is needed.
No fanfare of trumpets has announced the Bu-
reau’s progress and successes, here and there.
Only the communities which have been served
and the doctors who have found a satisfactoiy'
locale know and appreciate the Placement Bu-
reau’s efforts. It has solved in certain in-
stances and it continues its attempts to find a
practical answer to the problem of distributior-
of medical service in this State.

louR. M.S.M.S

MICHIGAN’S DEPARTMENT OF HEALTH

HENRY A. MOYER, M.D., Commissioner, Lansing, Michigan

MICHIGAN RECORD BETTER
THAN NATION

Michigan’s death rate was lower in 1940 than the
national average and the birth rate was higher, accord-
ing to provisional figures of the U. S. Public Health
Service.

The 1940 death rate for the state was 9.9 deaths
per 1,000 population, compared with 10.5 nationally.
The birth rate comparison is 18.8 for Michigan and
17.6 for the nation.

Among the five east north central states, Michi-
gan led the others in favorable rates. Wisconsin
was second low in death rate with 10.0 and the
other states had rates as follows: Illinois 11.2,

Indiana 11,3, Ohio 11.3. Wisconsin also was next
to Michigan in birth rates with a rate of 17.3. Other
rates were: Indiana 16.9, Ohio 16.3, Illinois 15.6.

Both the low death rate and the high birth rate for
1940 are in part due to Michigan’s young population.
MOiole families are still moving to Michigan and young
men and women still are coming into the state for
the same reason — opportunities for jobs.

As Michigan’s population grows older, our death
rate will go up and our birth rate will go down, but
these are long-time effects and probably will not be
apparent for years to come. As for the immediate
future, we may see a higher birth rate and a slightly
lower death rate in prospect for 1941.

POLIO CASES BELOW
AVERAGE

Infantile paralysis cases this year are under av-
erage figures. August cases reported to the Michi-
gan Department of Health totaled 59, compared
with a five-year average of 103. In last year’s
record epidemic, the August total was 304 and Sep-
tember cases totaled 508.

In August, no county except Wayne reported as
many as five cases of polio whereas last year 18
counties reported five or more cases. Wayne had
32 cases this year in August and of these 29 were
in Detroit. Only one case of polio was reported
from the Upper Peninsula in August. Last year
the Upper Peninsula was severely affected. With
only six per cent of the state’s population, the
Upper Peninsula in 1940 had 30 per cent of the
polio cases.

MSMS

CANCER PROGRAM
EXPANDED

Dr. F. L. Rector, for eleven years midwestern field
representative of the American Society for the Control
of Cancer, has been named cancer consultant for the
Department, to work with both lay and medical groups.
The appointment and working arrangements have the
approval of the State Society’s Cancer Committee,
headed by Dr. Wm. A. Hyland of Grand Rapids. In

(DUE TO NEISSERIA GONORRHEAE)

ciTi

ilver Picrate,
Wyeth, has a convincing record of
effectiveness as a local treatment for
acute anterior urethritis caused by
Neisseria gonorrheae.^ An aqueous
solution (0.5 percent) of silver pic-
rate or water-soluble jelly (0.5 per-
cent) are employed in the treatment.

Acomp/efe techniqueof treatment and liferaturewill besenfupon request

♦Silver Picrate is a definite crystalline compound of silver and picric acid.
It is available in the form of crystals and soluble trituration for the prepara-
tion of solutions, suppositories, water-soluble jelly, and powder for vaginal
insufflation.

1. Knight, F,, and Shelanski,
H. A., "Treatment of Acute Ante-
rior Urethritis with Silver Picrate,”
Am. J. Syph., Gon. & Ven. Dis.,
23, 201 (March), 1939.

JOHN WYETH & BROTHER, INCORPORATED, PHILADELPHIA

October, 1941

Say you saw it in the Journal of the Michigan State Medical Society

829

MICHIGAN’S DEPARTMENT OF HEALTH

WEHENKEL SANATORICM

A MODERN, comfortable sanatorium adequately equipped for all types of medical and
surgical treatment of tuberculosis. Sanatorium easily reached by way of Michigan
Highway Number 53 to Comer of Gates St., Romeo, Michigan.

For Detailed Information Regarding Rates and Admission Apply

DR. A. M. WEHENKELt Medical Director* City Offices* Madison 3312*3

his lay activities, Dr. Rector will be assisted by Miss
Grace Townsend, who has a background of teaching
and cancer research. The two were to join the De-
partment staff September IS.

Dr. Rector is known to the medical and health pro-
fessions of Michigan because of his field work with
the American Society for the Control of Cancer. He
made a survey of facilities for treating cancer in the
state in 1935 and the results were published in the
November, 1935, issue of The Journal of the Michigan
State Medical Society. He has spoken in many of
the cities of Michigan before medical societies and
hospital staffs, and before college, church, women’s
and other lay groups.

“Michigan is unique among the states for its joint
program of cancer education which the medical pro-
fession and the State Health Department are sponsor-
ing,” Dr. Rector said. “We shall try to bring its
benefits to every adult in the state.”

Dr. and Mrs. Rector live in Evanston, Illinois. He
was graduated at Oklahoma Agricultural and Mechani-
cal College and received his medical degree from George
Washington University at Washington.

Miss Townsend has done research and has taught
at the University of Chicago where she took her doctor-
ate in zeology and biochemistry. She has done re-
search at the Marine Biological Laboratory at Woods
Hole,_ Mass., on the chemistry of cell division and of
sensitivity of cells to the x-ray. Other institutions
where she has taught include Joliet high school and
junior college, Ohio State University and Miami Uni-
versity. Her work with the Department will be with
lay_ groups, including the Women’s Field Army of the
national cancer society.

MSMS

DIPHTHERIA OUTBREAKS
IN AUGUST

Two outbreaks of diphtheria which threatened to
become old-style epidemics were brought under con-
trol in August. Both were in Mexican migrant labor

830

families in sugar beet areas. Three deaths occurred.

At Blissfield, in Lenawee county, a colony of 246
persons was placed under quarantine after throat cul-
tures showed several carriers. The first cases were
reported by Dr. E. V. Tubbs, Blissfield village and
township health officer. An epidemiologist and the
mobile laboratory of the State Health Department were
sent to the colony, and throat swabs were taken of
every man, woman and each of the more than 100
children in the colony. Dr. T. M. Koppa, of the
Bureau of Epidemiology, went to Blissfield to assist
in control measures.

Twelve cases in children were reported, including
two deaths. Eighteen persons were found to be car-
riers. Antitoxin was used freely, and toxoid was given
to the children. Dr. Tubbs arranged for toxoid treat-
ment of all children in the village of Blissfield.

The other outbreak occurred in Saginaw county.
One death occurred, a baby. Four families were
isolated in the contagious unit of the Saginaw County
Hospital by Dr. V. K. Volk, Saginaw county health
officer.

MSMS—

NEW SANATORIUM
CONSULTANT

Consultation services for all tuberculosis sanatoria
receiving state aid are now being offered by the Michi-
gan Department of Health. Dr. Anthony D. Calomeni,
since 1938 physician-in-charge of the tuberculosis unit
of the Saginaw County Public Hospital, has been ap-
pointed consultant. A schedule is now being worked
out to bring these new consultation services of the
Bureau of Tuberculosis Control to both sanatoria and
health departments.

Prior to his work at Saginaw, Dr. Calomeni served
as resident physician at the William H. Maybury Sana-
torium in Northville. He is a member of the Saginaw
County Medical Society, the Michigan Trudeau and
the American Trudeau Societies, the Michigan Tuber-
culosis Association and the National Tuberculosis As-
sociation.

Jour. M.S.M.S.

IN MEMORIAM

IN MEMORIAM

Harry G. Bevington of Detroit was born in the
year 1877 and was graduated from Cleveland Pulte
Medical College in 1898. Following his internship
at Grace Hospital, Detroit, he entered general prac-
tice on the east side of Detroit. Later he establish-
ed an office in the David Whitney Building when
it was completed in 1915, which he continuously oc-
cupied until a few years ago, when his health com-
pelled him to restrict his work. He died on July
15, 1941.

A. Milton Campbell of Lansing was born in For-
est, Ontario on October 4, 1868, and was graduated
from the Detroit College of Medicine and Surgery
in 1898. He began his practice of medicine in Has-
lett, later moving to Lansing where he served the
people until January 1, 1941, when he gave up his
office because of ill health. Doctor Campbell, an
intimate friend of many athletes, was team physi-
cian for a number of years at Central High School.
He was a familiar figure on the side lines at all
local games and made many trips with the football
teams. He died August 17, 1941, after a long illness.

George A. Seybold of Jackson was born in 1881
and was graduated from the University of Michigan
Medical School in 1904. He was past president of
the Jackson County Medical Society, surgeon for the
Michigan Central Railroad and a fellow in the
American College of Surgery of the American Medi-
cal Association. Doctor Seybold served as a cap-
tain in the Medical Corps in the World War. He
died on September 6, 1941.

William H. Riley of Battle Creek was born in
Mattoax, Va., Feb. 5, 1860 and was graduated from
the University of Michigan Medical School in 1886.
He joined the Battle Creek Sanitarium staff the year
he graduated and was sent to its branch hospital
at Boulder, Colorado, where he served as director
for eight years. Doctor Riley won recognition as
a neurological diagnostician. He made many val-
uable contributions to the study of neurology, the
most important of which was his invention of the
ataxiagraph, used in studying incoordination of
the movement of the body. He served as head of
the neurology department of the Battle Creek Sani-
tarium from 1902 until his retirement on March 27,
1938. He was elected to Emeritus Membership of
the Michigan State Medical Society in 1939. Dr.
Riley died on Aug. 24, 1941.

John A. Schram of St. Joseph was born in Chi-
cago, in 1903 and was graduated from the University
of Indiana in 1931. He served his internship in
Methodist hospital at Indianapolis. Later he headed
the Rockefeller Foundation hospital in Ohio for a
year before establishing his practice in St. Joseph.
He died September 9, 1941.

i October, 1941

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831

-X COUNTY AND PERSONAL ACTIVITIES -x

One of the most fertile fields o£ malpractice litiga-
tion is the allegation on the part of a patient that in
reaching his diagnosis a physician did not use all neces-
sary and obtainable diagnostic aids. — Humphreys
Springstun, of the Detroit Bar. Doctors and Juries. P.
Blakiston’s Son and Co., Inc. 1935.

♦ * ♦

The American Association of Industrial Physicians
and Surgeons will hold its second annual meeting,
November 5 and 6, at Chicago Tower, Chicago, Illi-
nois. The interesting program may be obtained by
writing C. O. Sappington, M.D., 540 North Michigan
Avenue, Chicago.

* * *

The Tumor Clinic of the J. D. Munson Hospital,
Traverse City, was forced to change from monthly
to weekly meetings because of increased interest by
both physicians and patients. The present plan con-
sists of a Thursday noonday luncheon followed by
presentation and discussion of patients.

"Roentgen Therapy for Rheumatoid Arthritis of the
Spine’’ by C. J. Smyth, M.D. R. H. Freyberg, M.D.,
and Isadore Lampe, M.D., of Ann Arbor appeared in
the A.M.A. Journal of Sept. 6.

"Perpetuation of Error in Obstetrics and Gynecology”
by Norman F. Miller, AI.D., Ann Arbor, appeared in
J.A.M.A., Sept. 13, 1941.

* * *

Toledo University invites all members of the Michi-
gan State Medical Society to its annual Medical Post-
graduate Course, Friday, October 31, University Build-

ing, Toledo, Ohio. This year’s program will be a
round-table discussion led by McKeen Cattell, M.D.
Harry Gold, M.D., and Eugene F. DuBois, M.D..
members of the Department of Physiology of Cornell
University Medical College.

♦ * ♦

The Athletic Accident Benefit Plan of the Alichigan
High School Athletic Association published its first An-
nual Report for the 1940-41 school year on August
20. Nearly half of the high schools in the state (328)
participated in the Benefit Plan, registering 9,975
students for protection under the schedule of benefits.
A total of $10,550.20 was paid to member schools for
903 allowed injury benefits. For copy of this interest-
ing report, write C. E. Forsythe, Secretary, Athletic
Accident Benefit Plan, The Capitol, Lansing, Michigan.
♦ ♦ *

The American Association for the Study of Goiter
again offers the Van Meter Prize Award of Three
Hundred Dollars and two honorable mentions for the
best essays submitted concerning original work on
problems related to the thyroid gland. The Award
will be made at the annual meeting of the Association
which will be held at Atlanta, Georgia, June 1, 2, and
3.

The competing essays may cover either clinical on
research investigations; should not exceed three thou-1
sand words in length ; must be presented in English ; '
and a typewritten, double spaced copy sent to the
Secretary, T. C. Davison, M.D., 478 Peachtree Street, '
Atlanta, Georgia, not later than April 1. '

Ferguson -Droste- Ferguson Sanitarium

*

Ward S. Farg^uson, M. D. James C. Droste, M. D. Lynn A. Ferguson, M. D.

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DISEASES OF THE RECTUM

*

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GRAND RAPIDS. MICHIGAN

•I*

Sanitarium Hotel Accommodations

832

Jour. M.S.M.S.

COUNTY AND PERSONAL ACTIVITIES

Large Class Enters College of Medicine

A special “Welcome Day” for the largest class of
entering students in seven years at the College of
Medicine of Wayne University was held September
17 at the Gratiot-St. Antoine center.

Because of defense needs, special arrangements have
been made to accommodate 10 more medical students
than customarily are admitted each September. The
request for the increased quota was transmitted last
summer from the government through the Association
of American Medical Colleges.

The program for the medical group was in charge
of the College’s Student Council, and had been planned
by the Council president, James Doty, 2417 Crane.
Following a 1 :00 p.m. auditorium prograrn, the medi-
cal group toured college buildings and visited Receiv-
ing and St. Mary’s hospitals and the Board of Health
laboratories. '

♦ * ♦

Arthur Hitmphrey, M.D., Battle Creek,

1941 M.S.M.S. Golf Champion

The 1941 Golf Tournament of the Michigan State
Medical Society which was held over the beautiful
and sporty Kent Country Club, Grand Rapids, on
September 15, was won by Arthur Humphrey, M.D.,
of Battle Creek with a low of 83. Winner of the
Championship Flight and second low of the field was
George Slagle, M.D., also of Battle Creek. Doctor
Humphrey was awarded the Penberthy Trophy for one
year as well as the President’s Trophy, the latter
donated by P. R. Urmston, M.D., Bay City, president
of the Michigan State Medical Society.

Harry F. Dibble, M.D., Detroit, copped the Presi-
dent-Elect’s Prize donated by Henry R. Carstens, M.D.,
Detroit, with the low net score of the day.

C. F. Vale, M.D., Detroit, was the lucky winner of
a Bulova wrist watch in the Kicker’s Handicap. The
prize was donated by Bill Mennen.

Other winners were R. J. Paalman, M.D., Grand
Rapids, low net in the Championship Flight; A. M.
Putra, M.D., Detroit, low gross in the First Flight;
O. B. McGillicuddy, M.D., Lansing, low net in the
First Flight; R. M. McKean, M.D., Detroit, low gross
in the Second Flight; L. J. Morand, M.D., Detroit,
low net in the Second Flight; A. J. Baker, M.D.,
Grand Rapids, low gross in the Third Flight ; and
Henry A. Luce, M.D., Detroit, low net in the Third
Flight.

Don M. Howell, M.D., Alma, won the Maturity
Event limited to members 50 years of age and over by
shooting an 89. He took home the J. H. Dempster
Trophy for one year’s possession and the Treasurer’s
Prize donated by Wm. A. Hyland, M.D., of Grand
Rapids. Robert C. Jamieson, M.D., Detroit, and R. H.
Baribeau, M.D., Battle Creek, were runners up in the
Maturity Event.

Second and Third Prizes in the Kicker’s Handicap
were won by A. E. Catherwood, M.D., Detroit and
A. R. Dickson, M.D., Battle Creek.

M. J. Holdsworth, M.D., Grand Rapids, supervised
arrangements for the tournament.

Additional prize donors were : A. S. Brunk, M.D.,

Chairman of The Council ; O. D. Stryker, M.D., Speak-
er of the House of Delegates; L. Fernald Foster,
M.D., Secretary; Roy H, Holmes, M.D., Editor of
The Journal; H. H. Cummings, M.D., Vice Chairman
of The Council ; Wm. E. Barstow, M.D., Councilor
of the Eighth District ; W. H. Huron, M.D., Councilor
of the Thirteenth District ; A. H. Miller, M.D., Coun-
cilor of the Twelfth District; Vernor M. Moore, M.D.,
Councilor of the Fifth District; Wilfrid Haughey,
M.D., Councilor of the Third Councilor District ; Roy
C. Perkins, M.D., Councilor of the Tenth Councilor
District ; E. F. Sladek, M.D., Councilor of the Ninth
Councilor District; and Bill Burns, Executive Secre-
I tary.

1 October, 1941

Main Entrance

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Housebook giving details, pictures,
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Telephone 2140. Address,

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833

Say you saw it in the Journal of the Michigan State Medical Society

COUNTY AND PERSONAL ACTIVITIES

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COUNTY SOCIETY NEWS

The Grand Traverse Leelanau-Benzie County Medi-
cal Society held its annual Summer Clinic at Munson
Hospital, Traverse City, July 24-25, with an attendance
of fifty physicians.

Frederick A. Coder, M.D., of Ann Arbor and Grover
C. Penberthy, M.D., of Detroit, conducted operative
clinics during both morning sessions. Both afternoons
were devoted to lectures :

Frederick A. Coder, M.D., Ann Arbor : “War

Surgery.”

Cyrus C. Sturgis, M.D., Ann Arbor : “The Pur-

puric Anemias.”

Carl E. Badgley, M.D., Ann Arbor: “The Sulfon-

amides in Compound Fractures.”

Edgar A. Kahn, M.D., Ann Arbor ; “Some Signifi-
cant Neurological Signs in Everyday Medical Practice.”

William G. Gordon, M.D., Ann Arbor: “The Use

of Estrogenic Drugs in the Male.”

Grover C. Penberthy, M.D., Detroit : “The Use of

the Sulfonamides in Acute Osteomyelitis.”

Issac A. Abt, M.D., Chicago : “Congenital Mega-

colon.”

Following the Thursday evening banquet. Dr. Pen-
berthy showed a movie on the “Treatment of Burns,”
and C. E. Boys, M.D., of Kalamazoo showed a movie
on “Jaguar Hunting in Brazil.”

IVashtenaw County: S. W. Donaldson, M.D., Ann

Arbor, addressed the Society on “The Physician’s
Civil Liability.”

Following a historical introduction, the speaker dis-
cussed the physician’s rights, privileges, responsibili-
ties, and liabilities. Within this scope he defined
and discussed the contract between patient and physi-
cian, the responsibility of both parties under the con-
tract, and the mode of termination of this contract.

In a breach of this contract by the physician, a
malpractice suit may be instituted. This suit is an ac-
tion of tort or a civil wrong for which local redress
can be rendered by the awarding of many damages and
in which the law does not provide punitive action such
as a fine or imprisonment against the offender.

The discussion of malpractice suits was further
amplified by the consideration of a status of limitations
(in Michigan it is two years), malpractice defense,
and malpractice prophylaxis.

In a survey of 35,000 suits the following reasons
in order of importance constituting 90 per cent of
causes were given :

1. Inopportune remarks by subsequent attending phy-
sician.

2. Personal enmity and jealousy between members
of the profession.

3. Counter suits as a defense against the suit brought
by doctor for the purpose of collecting his fee.

4. Failure to use the x-ray with the diagnosis, and
reduction of a fracture.

The rule of privileged communication was defined
and thoroughly discussed. The importance of mal-
practice insurance was emphasized.

Because of the liklihood of all physicians to appear
sometime in court, importance of evidence and testi-
mony was stressed. The following suggestions were
given for the prospective physician witness on the
stand :

1. Before obligating yourself to testify as an expert,
except in a malpractice suit against a physician,
have a definite arrangement as to the fee.

2. Have a definite understanding of the merits of the
case.

3. If you have never appeared on the witness stand,
attend a few trials with the idea of hearing the
medical testimony and attempting to see the point
of view of the attorneys for both plaintiff and
defendant.

4. On the witness stand be honest and sincere.

Jour. M.S.M.S.

834

Say you saw it in the Journal of the Michigan State Medical Society

COUNTY AND PERSONAL ACTIVITIES

5. Be prepared. Expect anything on cross examina-
tion.

6. Be yourself.

7. Listen carefully to each question and be sure you
understand it. If it is not clear ask that it be re-
peated.

8. If you do not know, say so. A frank answer, even
though it is an admission of lack of knowledge, is
better than a bluff.

9. Do not lose your temper. Be as courteous to the
opposing counsel as you are to your own.

10. Do not volunteer testimony. Remarks which are
not necessary in answers to questions are liable to
bring forth objections that the testimony is irrele-
vant or to give the impression that the witness is
partisan. If you are serving as an ordinary witness,
give only the facts and state them clearly and con-
cisely. If called as an expert you are expected to
render an opinion.

11. Talk loudly enough to be heard. The judge, the
jury, the court stenographer and the attorneys must
hear everything you say. Speak directly to the jury,
as they especially need to know what you have to
say. If there is no jury, direct your remarks to the
judge.

12. Do not “play up to the spectators.” Try to act as
if you were in your own office discussing the case
with the attorney who summoned you.

READING NOTICES

ARMY RECOGNIZES
CANNED FOOD MANUAL

Recognition by the Quartermaster General in Wash-
ington was recently given to the “Canned Food Refer-
ence Manual.” The American Can Company was au-
thorized to send copies of the manual to the Com-
manding General and the Quartermaster at each Corps
Area Headquarters ; one to the Medical Officer and
the Quartermaster at each of the Posts, Camps and
Stations of the Army ; and one to the Commanding
Officer at the various Purchasing Depots of the Army
throughout the country.

PRESERVED BLOOD PLASMA

The stimulus of war has aroused great interest in
substitutes for whole blood, and many intensive investi-
gations are being undertaken in this field both from
the laboratory and clinical standpoints. The indica-
tions for intravenous administration of blood plasma,
such as in shock without hemorrhage, in bums, for
administration of antibodies and for the maintenance
of plasma protein, and even severe hemorrhage, are now
rather definite.

<ym FINANCIAL
^FIGURES

The DAILY LOG tells you at a glance how
your daily, monthly and annual business rec-
ords stand. Important non-financial records,
too. It has protected the earnings of
thousands of physicians for 14 yrs.
A life saver at income tax time!
WRITE — for booklet “The Adventures of
Doctor Young in the Field of Bookkeeping."

COLWELL PUBLISHING CO.

125 University Ave., Champaign, III.

October, 1941

to the Medical Profession

WHEN nothing less than a high degree of
accuracy in a clinical test or a chemical
analysis will serve your purpose, you can
send us your specimens with confidence.
Pleasant, well-equipped examining rooms
await your patients. In either the anal3dical
or the clinical department of our labora-
tory, your tests will be handled with the
thoroughness and exactitude which is our
undeviating routine. . . Fees are moderate.

Urine Analysis
Blood Chemistry
Hematology
Special Tests
Basal Metabolism
Serology

Parasitology

Mycology

Phenol Coefficients

Bacteriology

Poisons

Court Testimony

Directors: Joseph A. Wolf and Dorothy E. Wolf

Send j^ot 7gg

CENTRAL LABORATORIES

Clinical and Chemical Research
312 David Whitney Bldg. • Detroit, Michigan

Telephones: Cherry 1030 (Res.) Davison 1220

The question of sterility in stored plasma has led
many investigators to advocate the addition of “Mer-
thiolate” (Sodium Ethyl Mercuri Thiosalicylate, Lilly)
in a concentration of 1:10,000. “Merthiolate” has been
used for many years for the preservation of vaccines,
sera, and other biological products, and has been logi-
cally advocated for the preservation of blood plasma.
“Merthiolate” substance for the preservation of blood
serum and plasma may be added directly, or, more
conveniently, from a stock 1 per cent solution whicffi
should be made up fresh every thirty days. “Mer-
thiolate” substance for this purpose is obtainable from
the Indianapolis laboratories only.

REDUCTION IN RATES ANNOUNCED

The Physicians Casualty Association of America has
made a reduction in the $25.00 per week accident and
health insurance, of $1.00 per year; in the $50.00 per
week accident and health insurance, of $2.00 per year,
and in the $75.00 per week accident and health insur-
ance, of $3.00 per year.

SCHERING’S NEW SULFONAMIDE
NOW AVAILABLE FOR B USE

Sulfacetimide, a new and potent derivative of sul-
fanilamide, is to be marketed under the trade name
Sulamyd by the Scheering Corporation, Bloomfield,
New Jersey.

Sulfacetimide was highly praised at the recent meet-
ing of the American Medical Association in Cleveland
as “almost a specific for the treatment of B. coli in-
fections of the urinary tract.” The new drug is also
potent in the treatment of gonorrhea and other urinaiy
tract infections. Sulfacetimide is considered less toxic
than the sulfonamide preparations now available.

835

THE DOCTOR’S LIBRARY

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A. JAMES DeNIKE, M.D., Medical Superintendent

THE DOCTOR’S LIBRARY

Acknowledgment of ail hooks received will be made in this
column and this wUl be deemed by us as a full compensation
of those sending them. A selection will be made for review,^
as expedient.

OUTLINES OF INDUSTRIAL MEDICAL PRACTICE. By
Howard E. Collier, M.D. (Edin.) Ch.B., Formerly Reader in
Industrial Hygiene and Medicine, University of Birmingham.
Certifying Factory Surgeon, Etc. A William Wood Book.
Baltimore: The Williams & ^^’ilkins Company, 1941. Price:

$5.00.

While Industrial Hygiene in Great Britain apparently!
is not so well defined as in the United States the inti-J
mate details of this English book make it well worth
while. The material is recommended to all physicians
who have more than a passing interest in Industrial
Health. .

* * ♦

CEREBROSPINAL FEVER. By Denis Brinton, D.M. (Oxon),|l
F.R.C.P. (Lond.). Physician in Charge of the Department!
for Nervous Diseases, St. Mary’s Hospital, London; Assistant i!
Physician to Out-Patients, National Hospital for Nervous/]
Diseases, Queen Square, London: Physician to the RoyaRi

London Ophthalmic (Moorfield) Hospital, London; Consultant^
Neurologist to the London County Council. A William Wood3
Book. Baltimore: The Williams & Wilkins Company, 1941. n

Price: $3.00. |

The English view point of the “Universal Disease.”^
Emphasis is placed on the use of sulfonamides. The;;
only plates are four, and they are of sulfonamide 6
rashes. It is an interesting and instructive monograph. .
♦ ♦ ♦

ESSENTIALS OF DERMATOLOGY. By Norman Tobias.'
M.D., Senior Instructor in Dermatology. St. Louis Univer-
sity; Assistant Dermatologist, Firmin Desloge and St. Ma^’s i
Hospitals; Visiting Dermatologist, St. Louis City Sanitarium '
and Isolation Hospital. Philadelphia: J. B. Lippincott Com-

pany, 1941. Price: $4.75.

Eor the general practitioner and the medical student
the author presents in a simple fairly complete manner
all of the common skin ailments and most of the rarer
dermatoses. The treatment has been simplified and
is easily followed. Most of the pictures are new and
descriptive. It is surprising how the author has in-
cluded so much information in a small volume. It is
recommended for the general practitioner.

* * * ■“
THE AMERICAN ILLUSTR.\TED MEDICAL DICTIONARY.
A complete Dictionary of the Terms Used in Medicine,
Surgery, Dentistry, Pharmacy, Chemistry, Nursing, Veteri-
nary Science. Biology, Medical Biography, etc., with the
Pronunciation, Derivation, and Definition. By W. A. New- ■
man Dorland, A.M., M.U., F.A.C.S.; Lieut. -Colonel, M.R.C..
U. S. .\rmy; Member of the Committee on Nomenclature and
Classification of Diseases of the American Medical Associa-
tion; Editor of “American Pocket Medical Dictionary.”
Nineteenth Edition, revised and enlarged with 914 illustra-

THE MAPLES

A Private Sanitarium for the Treatment of Alcoholism

Registered by the A.M.A.

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Jour. M.S.M.S. \

836

Say yon saw it in the Journal of the Michigan State Medical Society

THE DOCTOR’S LIBRARY

tions, including 269 portraits. With the collaboration of

E. C. L. Miller, M.D., Medical College of Virginia. Phila-
delphia and London; W. B. Saunders Company, 1941.
Price; Plain, $7.00; Thumb-Indexed, $7.50.

w

This is the nineteenth edition of a volume first pub-
lished in 1900. In this edition more than two thousand
new words have been added. There are well over a
hundred tables and several hundred portraits besides
the usual dictionary features. This is the dictionary
in which the editorial department of the American
Medical Association cooperates. The typography and
binding are very good.

* * *

MODERN MARRIAGE. A Handbook for Men. By Paul
Popenoe, General Director, the American Institute of Family
Relations, Los Angeles, Calif.; Lecturer in Biology, Uni-
versity of Southern California. Second Edition. New York;
The iSlacMillan Company, 1940. Price; $2.50.

Popenoe is a Lecturer in Biology and approaches the
ii subject of marriage from the biological point of view.

An entire chapter is devoted to proposals including a
table of the number of proposals the average woman
of a certain age group receives. The volume should
-i be of some value to the physician who wishes some
^ means of informing the young man who is serious
4 j about the whole thing.

* * *

MANUAL OF THE DISEASES OF THE EYE. For Students
and General Practitioners. By Charles H. May, M.D., Con-
sulting Ophthalmologist to Bellevue, Mt. Sinai and French
Hospitals, New York; Formerly Chief of Clinic and In-
structor in Ophthalmology, Medical Department of Columbia
University, and Director of the Eye Service at Bellevue Hos-
pital, New York. Seventeenth Edition, Revised with the
assistance of Charles A. Perera, M.D., Associate in Ophthal-
mology, College of Physicians and Surgeons, Medical Depart-
ment of Columbia University, New York; Asst. Attending
Ophthalmologist, Presbyterian Hospital, New York. With
.^87 illustrations including 32 plates, with 93 colored figures.
Baltimore: William Wood and Company, 1941. Price; $4.00.

William Wood and Company presents the seventeenth
edition of May’s “Manual of the Diseases of the Eye”
originally published in 1900. This standard textbook
includes appropriately, an appendix giving the oc-
ular requirements for admission to the Army, Navy,
Marine and Air Service in the United States. The
changes necessitated by recent advances in this sub-
ject in the last two years have been added and some
parts have been rewritten. This book provides an ex-
cellent reference for the general practitioner who needs
assistance in common ophthalmological conditions.

4= * *

NECROPSY. A Guide for Students of Anatomic Pathology.
By Bela Helpart, M.D.,_ Assistant Professor of Pathology
and Bacteriology, Louisiana State University School of
Medicine, and Visiting Pathologist, Charity Hosptal of Louisi-
,ana at New Orleans. St. Louis; The C. V. Mosby Com-
pany, 1941. Price: $1.50.

This is a handy practical protocol which cannot help
but produce a valuable autopsy if the outline and sug-
gestions of the author are followed.

4: 4: *

ABDOMINAL SURGERY OF INFANCY AND CHILD-
HOOD. By William E. Ladd, M.D., F.A.C.S., William E.
Ladd Professor of Child Surgery at Harvard Medical School ;
Chief of Surgical Service, The Children’s Hospital, Boston;
and Robert E. Gross, M.D., Associate in Surgery, the
Harvard Medical School ; Associate Visiting Surgeon, The
Children’s Hospital : Associate in Surgery, The Peter Bent
Brigham Hospital, Boston. Philadelphia and London: W. B.

Saunders Company, 1941. Price: $10.00.

The surgical staff members of the Boston Children’s
' Hospital believe that good results in surgery of the
younger group of children could not be expected if
the patient were treated simply as a diminutive man or
woman. They began to devote the major part of their
time to pediatric surgery. They did this not to set
pediatric surgery apart as a separate speciality but to
.emphasize the fact that infants and children can obtain
improved surgical care if an appropriate number of
men in each community will take a particular interest

October, 1941

worth while laboratory exam~
inations; including —

Tissue Diagnosis

The Wassermann and Kahn Tests

Blood Chemistry

Bacteriology and Clinical Pathology

Basal Metabolism

Aschheim-Zondek Pregnancy Test

Intravenous Therapy with rest rooms for
Patients,

Electrocardiograms

Central Laboratory

Oliver W. Lohr, M.D., Director

537 Millard St.

Saginaw

Phone, Dial 2-3893

The pathologist in direction is recognized
by the Council on Medical Education
and Hospitals of the A. M. A.

PllOKSSIOHAL|>llOrOOM

A DOCTOR SAYS:

“My policy with you was a great com-
fort to me — far greater than I could
realize before the suit was entered. I
have been repaid a hundred fold for
the money expended.”

OF

837

THE DOCTOR’S LIBRARY

86c out of each $1.00 gross income
used for members benefit

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(56,000 Policies in Force)

LIBERAL HOSPITAL EXPENSE
COVERAGE

For
$10.00
per year

$5,000.00 ACCIDENTAL DEATH

$25.00 weekly indemnity, accident and sickness

For
$32.00
per year

$10,000.00 ACCIDENTAL DEATH

$50.00 weekly indemnity, accident and sickness

For
$64.00
per year

$15,000.00 ACCIDENTAL DEATH

$75.00 weekly indemnity, accident and sickness

For
$96.00
per year

39 years under the same management

$2,000,000.00 INVESTED ASSETS
$10,000,000.00 PAID FOR CLAIMS

$200,000 deposited with State of Nebraska for pro-
tection of our members.

Disability need not be incurred in line of duty — benefits
from the beginning day of disability.

Send for applications, Doctor, to

400 First National Bank Building Omaha, Nebraska

LABORATORY APPARATUS

Coors Porcelain
Pyrex Glassware
R. & B. Calibrated Ware
(.'hemical Thermometers
Hydrometers
Sphygmomanometers

J. J. Baker & Co., C. P. Chemicals
Stains and Reagents
Standard Solutions

• BIOLOGICALS*

Serums Vaccines

Antitoxins Media

Bacterins Pollens

We are completely equipped and solicit
your inquiry for these lines as well as for
Pharmaceuticals, Chemicals and Supplies,
Surgical Instruments and Dressings.

^Ue RUPP & BOWMAN GO.

319 SUPERIOR ST., TOLEDO, OHIO

in this field. This volume deals with abdominal surgery
of this age group and is well illustrated with line
drawings and cuts and discusses informatively the
variations which are found, in children. For the pedia-
trician and the surgeon this book should be of con-
siderable importance and to the general practitioner, of
value.

♦ ♦ ♦

Annual Reprints of the Reports of the COUNCIL ON PH.AR-
MACY AND CHEMISTRY of the American Medical Associa-
tion for 1940. With the comments that have appeared in
The Journal. Chicago; American Medical Association, '1941.
Price: $1.00.

The American Medical Association has published this
small volume giving the reports of the Council on
Pharmacy and Chemistry together with the comments
which have appeared in The Journal of the A.M.A.
For a permanent reference of the truth on new drugs
this book is recommended to all physicians.

CLASSIFIED ADVERTISING

TEN-BED, BRICK VENEER HOSPITAL and good
general practice to sell. Excellent prospect for a
doctor with moderate capital who likes small town
life and out door activities. Full information can
be obtained by writing to the Executive Office,
Michigan State Medical Society, 2020 Olds Tower,
Lansing, Michigan — Box 19.

The Mary E. Pogue School

For Exceptional Children

DOCTORS: You may continue to super-
vise the treatment and care of children
you place in our school. Catalogue on
request.

WHEATON, ILLINOIS

85 Geneva Road Telephone Wheaton 66

Physicians' Service Laboratory

608 Kales Bldg. — 76 W. Adams Ave.
Northwest corner of Grand Circus Park

Detroit, Michigan

Kahn and Kline Test
Blood Count

Complete Blood Chemistry
Tissue Examination
Allergy Tests
Basal Metabolic Rate
Autogenous Vaccines

CAdillac 7940

Complete Urine Examina-
tion

Ascheiin-Zonde

(Pregnancy)

Smear Examination
Darkfield Examination

All types of mailing containers supplied.
Reports by mail, phone and telegraph.
Write for further information and Prices.

Jour. M.S.M.S.

838

Say you sazv it in the Journal of the Michigan State Medical Society

EXZYMOL

A Physiological Surgical Solvent

Prepared Directly From the Fresh Gastric Mucous Membrane

ENZYMOL proves of speeded service in the treatment of pus cases.

ENZYMOL resolves necrotic tissue, exerts a reparative action, dissipates foul odors;
a physiologiced, enzymic surface action. It does not invade healthy tissue; does not
damage the skin. It is made ready for use, simply by the addition of water.

These are some notes of clinical application during many years:

Abscess eexvities
Antrum operation
Sinus cases
Comeal ulcer

Carbuncle
Rectal fistula
Diabetic gangrene
After removal of tonsils

After tooth extraction
Cleansing mastoid
Middle ear
Cervicitis

Originated and Made by

Fairchild Bros. & Foster

New York, N.Y.

Descriptive Literature Gladly Sent on Request.

FOR THIS PATIENT-
A BURDICK RHYTHMIC CONSTRICTOR

Disorders of the peripheral circulation with a di-
minished flow of blood through the extremities are
amenable to treatment with a

Constrictor

Smooth and silent in action, inexpensive to operate, and clinically effective, the Burdick
Rhythmic Constrictor is of distinct merit in — peripheral vascular sclerosis, early thrombo-
angiitis obliterans, acute vascular occlusion, diabetic ulcers, intermittent claudication,
chilblains and frostbite.

Selective Dual Timing makes it possible for you to individualize treatments in each case.

-THE G. A. INGRAM COMPANY

4444 Woodward Ave. Detroit, Michigan

The G. A. INGRAM CO« 4444 Woodward Ave., Detroit, Michigan
Please send me full information on the Burdick Rhythmic Constrictor.

Dr

Address

City State

November, 1941

Say you saw it in the Journal of the Michigan State Medical Society

847

I

MICfflGAN MEDICAL SERVICE

At the annual meeting of the members of
Michigan Medical Service, elections were held
to complete the Board of Directors of the Corpo-
ration. The Board at present is constituted as
follows ;

Representing the Medical Profession

Otto O. Beck, M.D., Birmingham, Councilor, MSMS

A. S. Brunk, M.D., Detroit, Chairman of The Coun-
cil, MSMS

Wm. J. Burns, Lansing, Executive Secretary, MSMS

E. I. Carr, M.D., Lansing

Henry R. Carstens, M.D., President, MSMS

B. R. Corbus, M.D., Grand Rapids, Past President,
MSMS

H. H. Cummings, M.D., Ann Arbor, President Elect,
MSMS

T. E. De Gurse, M.D., Marine City, Councilor,
MSMS

L. Fernald Foster, M.D., Bay City, Secretary, MSMS
Wilfrid Haughey, M.D., Battle Creek
R. H. Holmes, M.D., Muskegon, Editor of the
Journal, MSMS

W. H. Huron, M.D., Iron Mountain, Councilor,
MSMS

Wm. A. Hyland, M.D., Grand Rapids, Treasurer,
MSMS

P. L. Ledwidge, M.D., Detroit, Speaker of the
House of Delegates, MSMS
Harold J. Kullman, M.D., Detroit
Henry A. Luce, M.D., Detroit, Past President, MSMS
Vernor M. Moore, M.D., Grand Rapids, Councilor,
MSMS

Ray S. Morrish, M.D., Flint, Councilor, MSMS
R. L. Novy, M.D., Detroit

P. A. Riley, M.D., Jackson, Past Speaker, House of
Delegates, MSMS
Ralph Pino, M.D., Detroit

F. J. Sladen, M.D., Detroit

O. D. Stryker, M.D., Fremont

P. R. Urmston, M.D., Bay City, Past President,
MSMS

Representing Lay Groups

Mr. George J. Burke, Ann Arbor, Burke & Burke,
Attorneys

Mr. Ernest H. Fletcher, Detroit, Fletcher, Van Tif-
flin & Rose, Accountants

Mr. Richard Frankensteen, Detroit, Congress for In-
dustrial Organization

Mr. Robert Greve, Ann Arbor, Michigan Hospital
Association

Mrs. Kate Hard, Saginaw, Saginaw General Hospital
Harley Haynes, M.D., Ann Arbor, Michigan Hospital
Association

Mr. Wm. J. Norton, Detroit, Children’s Fund of
Michigan, Past President, Michigan Welfare
League

Mr. N. Earl Pinney, Detroit, Mutual Benefit Life
Insurance Company

Mr. John Reid, Lansing, American Federation of
Labor

Mrs. Dora H. Stockman, Lansing, Michigan State
Grange, Member of the House of Representatives

Mr. Harry Talliaferro, Grand Rapids, President,
American Seating Company

The present Board of Directors includes a full
representation of the medical profession by
Councilor Districts. Likewise, as provided in the
governing law, proper representation is given to
the public through lay members.

Points of Information

Two phases of the operation of Michigan
Medical Service are of particular interest:
( 1 ) Why is there some delay in making pay-
ments to doctors; (2) Why was the pro ration
necessary.

Why Some Delay in Making Payments to
Doctors. — The majority of Service Reports re-
ceived by the tenth of the month following the
month of service are approved by the Medical
Advisory Board for payment by the fifteenth of
the month. Checks are then drawn so that pay-
ments are received by doctors before the thirtieth
of the month following the month of service.

The chief reason for any delayed payment is
late reporting of services by the doctor’s office.
At least 40 per cent of the service reports are re-
ceived one or more months late. Many of the re-
ports received are incompletely filled out or do not
present sufficient information to identify the pa-
tient as a subscriber. Consequently, there may be
delay in ascertaining whether the patient is eligi-
ble for services and in having the report approved
for payment.

In a small percentage of the cases there may
be some delay because of a precedent type of
service which necessitates the obtaining of special
information through the Medical Advisory
Boards or other committees before appropriate
payment can be authorized.

At the meeting in Grand Rapids, there was a
general session for doctors’ office secretaries to
acquaint them with the procedures for billing
Michigan Medical Service. Outlines of the ar-
rangements for billing have been distributed
widely. Prompt payment will be facilitated if the

Jour. M.S.M.S.

848

-★

• The name is never abbreviated;
other infant food — notivithstanding

and the product is not like any
a confusing similarity of names.

The fat of Similac has a physical and chemical composi-
tion that permits a fat retention comparable to that of
breast milk fat (Holt, Tidwell & Kirk, Acta Pediatrica,
Vol. XVI, 1933) ... In Similac the proteins are rendered
soluble to a point approximating the soluble proteins in
human milk . . . Similac, like breast milk, has a con-
sistently ZERO curd tension . . . The salt balance of
Similac is strikingly like that of human milk (C. W.
Martin, M. D., New York State Journal of Medicine,
Sept. 1, 1932). No other substitute resembles breast milk
in all of these respects.

A powdered, modified
milk product especially
prepared for infant feed-
ing, made from tuber-
culin tested cow’s milk
(casein modified) from
which part of the butter
fat is removed and to
which has been
added lactose, vegetable
oils and cod liver oil
concentrate.

SIMILAR TO
BREAST MILK

M&R DIETETIC LABORATORIES, INC. • COLUMBUS, OHIO

November, 1941

Say you saw it m the Journal of the Michigan State Medical Society

849

MICHIGAN MEDICAL SERVICE

doctor will see that his office carries out the fol-
lowing simple procedures :

(a) Send the Initial Service Report immedi-
ately when services are first requested,
entering the correct name, address and
certificate number of the patient and
designating the services required. Fail-
ure to send the Initial Service Report
immediately will delay authorization of
payments. If the Initial Service Report
is not sent promptly, there is no need to
send this report along with the Monthly
Service Report.

(b) Send the Monthly Service Report, des-
ignating the exact services rendered and
indicating the patient’s name and certifi-
cate number, not later than a few days
following the month during which serv-
ices were rendered.

Monthly Service Reports should be
sent for services rendered during each
month.

The office personnel and procedures of Mich-
igan Medical Service are constantly improving
and doctors may expect that reports sent in on
time will be paid promptly. If your report is not
paid promptly, do not send another Monthly
Service Report ; simply send a letter giving the
full name of the patient and the date of services,
with a request that payment be remitted.

IVhy Was Proration Necessary? — After pay-
ment of the full Schedule of Benefits for thirteen
consecutive months, the combination of a great-
ly increased volume of services and late reporting-
on the part of the doctors made it necessary to
pay on a prorated basis of 80 per cent until a de-
termination could be made of the cost of services
for the particular month compared with the in-
come from subscribers. This determination can
be made only when all late reports are received,
which means after a period of at least 90 days
following the month of services, during which
time reports may be authorized for payment. It
is recognized that the prorated payments are
tentative and that the reduced amount is an ob-
ligation that will be repayable to the doctors out
of surpluses that may be accumulated.

It is also believed that the prospects for re-
payment are favorable. An analysis of groups
that have been enrolled for twelve months indi-

cates that the income is more than sufficient to
cover the cost of services and administration ex-

pense. During the first five months of enrollment
there is a large volume of services required for
the correction of pre-existing conditions such as
female pelvic disorders, hernias, appendectomies,
and tonsillectomies. In subsequent months, costs
of services are less. Experience records also
show that one-half of all appendectomies and ton-
sillectomies required by a group of subscribers
will be performed during the first few months of
enrollment.

In addition to the improved financial status for
groups enrolled longer than five months, the pres-
ent season of the year from September to Jan-
uary is a period of lower utilization of services.

Harper Hospital Bulletin-, a new publication by mem-
bers of the Harper Hospital Staff, Detroit, Michigan,
will appear monthly from October to June. Members
of the profession may obtain copies of the Harper Hos- .
pital Bulletin by addressing The Editor, 3825 Brush
Street, Detroit, ^lichigan. 1

The Editorial Board consists of the following: <

Editor in Chief — Harold C. Mack, M.D. I

Assistant Editor — Gaylord S. Bates, M.D.

Departmental Editors : Surgery — Harold B. Fenech, 4

M.D. ; Internal Medicine — William Reveno, M.D. ; Oto- i
laryngology- — Arthur Hammond, M.D. ; Ophthalmology 1
— Arthur Hale, M.D. ; Pathology — Lawrence Gardner, |
M.D. ; Obstetrics and Gynecolo^- — Roger Siddall, M.D. ; !
Roentgenology — Traian Leucutia, M.D. i

PllOr{$SOMAl|>llOIKTIOM

A DOCTOR SAYS:

“Unless one has gone through the ex- ]

perience of a suit, or threatened suit, he '■

is not likely to appreciate the great com-
fort it is to have professional protec-
tion. Our policy u'ith you certainly
gave us many a good night’s sleep and
kept us from many a headache.” |

OF

Jour. M.S.M.S. |

850

Q. I’ve heard that some varieties of canned marine fish are
good sources of vitamin D. Is that true?

A. Yes, it is. A four-ounce serving of canned salmon contains
approximately 200 to 800 U.S.P. units of vitamin D-2.
The body oils of sardines approach a good cod liver oil in
vitamin A and D potencies. Therefore, canned sardines
are another important dietary source of vitamin D. (l )
It has been reliably estimated that the amount of canned
salmon sold in this country alone contains more vitamin D
than the cod liver oil used for both animal and human
feeding. (2)

American Can Company, 230 Park Avenue, New York, N. Y.

m

1935. J. Home Econ. 27, 658.

(2)

1931. Ind. Eng. Chem. 23, 1066.

The Seal of Acceptance denotes that the nutri-
tional statements in this advertisement are accept-
^ able to the Council on Foods and Nutrition

of the American Medical Association.

November, 1941

Say you saw it in the Journal of the Michigan State Medical Society

851

>f HALF A CENTURY AGO X-

THE NEED FOR A BETTER STUDY OF DISEASES OF THE SKIN*

W. F. BREAKEY, M.D.

Ann Arbor, Michigan

It is not claimed that this paper presents ideas espe-
cially original or new in matter or form ; and the prin-
cipal excuse, if not justification, it can have is the, per-
haps, presumptuous opinion that there is still need for
repetition of effort to rescue from quackery a branch of
medicine too much given over to the charlatan and to
encourage more study of it by the general practitioner,
as alike beneficial to his patients, creditable to medical
science, and profitable to himself. If it be the means
of encouraging any practitioner to more thorough in-
vestigation and successful treatment of a class of cases
that have been too much the opprobrium of medicine, it
will not be wholly in vain.

Its exterior position, great area, and peculiar func-
tions, make the skin an important organ from a hygienic
point of view. From a pathological and therapeutical
standpoint, the importance of a knowledge of the dis-
eases of the skin, to the general practitioner of medi-
cine, is so obvious as not to need argument.

Considering the extent of surface of the skin, the
wonderful adaptability to the successful performance
of its varied and important functions, its protection to
subjacent tissues, while it is also the principal terminus
of sensory nerves, serving also as a great eliminator
and emunctory ; its tolerance of heat and cold ; its ex-
posure to injuries, to atmospheric and other poisons
and irritants, by contact, by textures and colors of
clothing, by its lack of care, and by mal-medication ;
to say nothing of parasitic, inherited, or exanthematous
diseases — when we consider these and many unmen-
tioned risks, it is not strange that the skin is the seat of
such a variety of diseases.

It is the medium through which external influences
act on the body, and the channel by which many com-
municable diseases find their way to other organs and
tissues. Beside the diseases to which its own tissues
are subject, its conditions often furnish indications of
disease of other organs. It will be generally conceded
by the average medical man that while modern medical
science has taught us much of the structure and func-
tion of the skin, we have not made corresponding
progress in the hygienic care or successful treatment
of its diseases.

Indeed, it is only stating it moderately to say, that
the whole field of diseases of the skin and its ap-
pendages, has been too much neglected by the general
practitioner. This, however, is not wholly his fault,
as the colleges, also, until within a very few years, have
given students very insufficient instruction and facilities
for the study of dermatology.

And the people who are too prone, at best, to trust
themselves to advisers who promise the most — even if
irresponsible — in these cases are furnished an excuse
for patronizing quackery, by reason of the failure of
the general practitioner to give them sufficient attention.

It is curious that while some practitioners seem to
have thought it too difficult for the ordinary physician,
others have regarded it as too trivial to study the
pathology of diseases of the skin. Others too, have
underrated the importance of these cases, because so

*Presented at the twenty-sixth annual meeting- of the Michi-
gan State Medical Society at Saginaw in 1891.

852

many of them do not endanger life, and are often
found in persons of otherwise good health. But it
should be remembered that many disorders of the skin,
which appear slight, may cause much distress to those
afflicted ; others are important or serious because of
their bearing upon the general health and usefulness of
the sufferers and their friends. Some are attended %\4th
much irritation and pain. Many cases cause great dis-
figurement, and are regarded with a sort of instinctive
abhorrence. There is a tendency in the popular mind
to classify all unsightly diseases of the skin as com-
municable. Thus the subjects of innocent cases of
acne, eczema, and psoriasis are sometimes shunned as
lepers, or subjected to suspicion of having inherited or
acquired a disease in some way discreditable to their
morals, while less conspicuous but genuine cases of
syphilis go unchallenged and unguarded. And this
popular misconception is often strengthened by errone-
ous or thoughtless professional opinion.

The supposed difficulties of a successful study of skin
diseases have been exaggerated, by the idea that the
pathology was different from that of other tissues.
Hillier wrote 25 years ago that, “Probably no class
of diseases was less understood,” and other authors,
foreign and American, have, in one way and another,
repeated the statement later. Prominent among the
causes of this difficulty is the great diversity of names
which have been given to diseases of the skin, by
different authors, some diseases having several different
names, and the same name having been given to diseases
totally distinct from each other. Even the same writer
has given new names to diseases described previously
by himself under other names! And, as if this was not
enough to confuse, the difficulties were further increased
by “endless varieties of classification and extreme sub-
division,” “the same disease being given different names,
from the different appearances presented in different
stages of its progress, or variations in severity,” etc.

As indicating progress. Fox (F.S.), writing 15 years
later than Hillier, says as to the general character of
skin diseases : “There is nothing especially in the path-
ological changes occurring in the tissues in these dis-
orders

That the idea of the student that he is about to en-
counter a “new set of pathological phenomena” is not
true;

That (then) recent researches in cutaneous pathology
have cleared the way to a more correct knowledge of
the changes taking place in the skin in disease, and as
a consequence, it is becoming more and more apparent,
that these morbid processes are identical with those
occurring elsewhere in the body. And it is still more
noteworthy and satisfactory now than then, that the
student of today who is compelled to acquire patho-
logical knowledge over so wide a field, is beginning to
discover that his study of skin diseases is rendered
comparatively easy, because of the complete similarity
which has now been demonstrated between the facts of
general and skin pathology.

As Taylor so aptly states, it will therefore be seen
that skin diseases are intimately allied to the general
(Continued on Page 856)

Jour. M.S.M.S.

^ SEE YOUR DOCTOR*^ Reproduced below is Number 171

of a series of full-page advertisements published by Parke, Davis & Co.
in the interest of the medical profession. This ''See Your Doctor" cam-
paign has been running in The Saturday Evening Post and other leading
magazines for thirteen years.

The man who nearly died . . . from a few kind words

T>eyond that door lies a very sick man.

True, his doctor says he is going to pull
through. But he has come mighty close to
paying a tragic price for a few words of free
advice from a well-meaning friend.

When he complained of a nagging pain
in his abdomen, his friend said: "You’ve
probably eaten something that’s poisoned
you. Here’s what I’d do . . .”

So he promptly followed his friend’s sug-
gestion and took a cathartic. And in a mat-
ter of hours he was being rushed by ambu-
lance to the hospital . . . with a ruptured
appendix.

November, 1941

His friend, of course, had acted from the
kindest of motives. But he didn’t know that
an abdominal pain might mean acute ap-
pendicitis, in which case a cathartic should
never be taken.

Unfortunately, appendicitis is only one
of many illnesses where amateur medical
advice can result in tragedy. Yet, human
nature being what it is, many people just
can’t resist the temptation to offer advice
when a friend is sick.

Intelligent medical treatment depends
upon various factors which only a physician
is qualified to evaluate. When something

seems wrong with you, it is the part of wis-
dom to observe this common-sense rule:
Take a friend’s advice about buying a radio,
a car, or even a home if you wish; but don’t
let him advise you about your health.

Don’t let a friend who means well tell you
how to get well. To get well, and keep well,
the man to see is your physician.

Copyright. 19441. Parke, Davis k Co.

PARKE, DAVIS & COMPANY

Detroit, Michigan

Seventy-five years of service to
medicine and pharmacy

SEE YOUR DOCTOR

853

Say you saw it in the Journal of the Michigan State Medical Society

COUNTY AND DISTRICT MEETINCS

COUNTY MEDICAL SOCIETY MEETINGS

Bay — Wednesday, October 8, 1941 — Bay City —

Berrien — Wednesday, August 13, 1941 — Benton Har-
bor— Speaker ; LeMoyne Snyder, M.D., Lansing. Sub-
ject: “Scientific Investigation of Evidence.” Thursday,
September 25 — Benton Harbor — Speaker : C. S. Scuderi,
M.D., Chicago. Subject: “Treatment of Compound
Fractures.” Wednesday, October 15 — Niles — Speaker :
Carl Langenbahn, M.D., South Bend, Indiana. Subject:
“Surgical Aspects of Hematuria.”

Calhoun — Tuesday, September 9, 1941 — Battle Creek
■ — Speaker: Walter Schiller, M.D., Chicago. Subject:
“New Aspects in Relation to Pathology of Ovarian
Tumors.” Tuesday, October 7, 1941 — Battle Creek —
Speaker : Herman H. Riecker, M.D., Ann Arbor. Sub-
ject: “Classification and Management of Hypertension.”

Delta-Schoolcraft — Wednesday, October 29, 1941 —
Escanaba — Speaker: M. Cooperstock, M.D., Marquette.
Subject: “Care of the Premature Baby.”

Dickinson-Iron — Thursday, September 4, 1941- — Iron
Mountain.

Ingham — Tuesday, September 9, 1941 — Lansing —

Speaker: LeMoyne Snyder, M.D., Lansing. Subject:
“Medical Evidence.”

lonia-Montcalm — Tuesday, October 14, 1941 — Lake
Odessa — Speaker: Leland M. McKinley, M.D., Grand
Rapids — Subject: “Newer Concepts and Treatment of
Shock.”

Kalamazoo — Tuesday, October 21, 1941 — Fort Custer
— Program by medical officers at Fort Custer.

Kent — Tuesday, October 14, 1941 — ^Grand Rapids —
Speaker: A. C. Corcoran, M.D., Indianapolis. Sub-
ject : “Recent Advances in the Study of Hypertension.”

Marquette-AIger — Tuesday, Septeml>er 30, 1941 —

Marquette — Speaker : Frank V. Theis, M.D., Chicago.
Subject: “Diagnosis and Treatment of Peripheral Cir-
culatory Disturbances.”

Muskegon — Friday, September 19, 1941 — Muskegon —
Speaker: H. Ivan Sippy, AI.D., Chicago. Subject:
“Gastro-Intestinal Disorders.” Friday, October 17 —
Muskegon — Program of medical motion pictures.

Northern Michigan — The Northern Michigan Medical
Society adopted the following resolution at its August
meeting :

“Whereas, Schedule A represents the lowest sched-
ule of fees that physicians can work under (i.e., cost
price or one-half regular fees;

“And Where.as, In the past the members of the
Northern Michigan Medical Society have done county
and state work at less than cost prices ;

“And Whereas, Federal governmental agencies dur-
ing the present emergency are demanding more and
more work from physicians without compensation,
necessitating that they be paid at least cost price for
county and state work;

“And Whereias, the rising costs of living, medicines,
salaries, et cetera, have increased the physicians’ ex-
pense in delivering service ;

“Be It Resolved, That the members of the Northern
Michigan Medical Society hereby notify the Social
Welfare Boards of the counties of Emmet, Cheboygan,
Charlevoix, and Antrim that, starting September 15,
1941, Schedule A of 1937 as outlined by the Michigan
Crippled Children Commission will be the minimum
fees at which services will be performed for the county
Social Welfare Boards.”

Shiazmssee — Thursday, October 16, 1941 — Owosso —
Speaker : J. M. Brandel, M.D., Owosso, will present
and discuss motion picture on electrocardiography.

IVashtennzje — Tuesday, October 14, 1941 — Ann Arbor
— Speaker: Otto Engelke, M.D., Ann Arbor. Subject:
“Washtenaw County Health Unit.”

IVayne — Monday, October 6, 1941 — Detroit — Speaker :
D. W. Gordon, Murray, M.D., Toronto. Subject: “The
Use of Heparin in Blood Vessel Surgery and Throm-

bosis. Monday, October 20 — Detroit — General Prac- 1
tice Meeting. Joint session with Detroit Dermatological
Society ; round table on dermatology. Mondaj', October I
27 — Detroit — Speaker: Michael L. Mason, M.D., Chi- 1
cago. Subject: “Significant Factors in the Development I
of Infections of the Hand.” Monday, November 10—
Detroit — Speaker: Ernest E. Irons, M.D., Chicago-
Subject: “Aspiration Pneumonia.” Monday, Novemlxrr|
24 — Detroit — Surgical Meeting. Speaker: Frederick A.
Coller, M.D., Ann Arbor |

West Side (lErtync)— Wednesday, October 15, 1941 1
— Detroit — Social meeting for doctors and their wive'. 1

MSMS DISTRICT MEETINGS IN FULL SWING

The following Councilor District meetings have
been arranged or already have been held : Seventh
District at Marlette on October 14, T. E. DeGurse,
M.D., Councilor. Other officers attending included Coun-
cil Chairman A. S. Brunk, Detroit ; Speaker P. L. Led-
widge, Detroit; Secretary L. Fernald Foster, Bay Citv;
and Executive Secretary Win. J. Burns.

The Tenth District met at Grayling on October 21,
Roy C. Perkins, M.D., Councilor. MSMS officers at-
tending included W. E. Barstow, M.D., St. Louis; E. F.
Sladek, M.D., Traverse Cit}’; Secretary Foster and J
Executive Secretary Burns. B

The Third District met at Battle Creek on October
28, Wilfrid Haughey, !M.D., Councilor. MSMS officers
included President H. R. Carstens, M.D., Detroit; \'er-
nor ^1. Moore, M.D., Grand Rapids; R. J. Hubbell,
M.D., Kalamazoo; Secretary Foster and Executive
Secretary Burns.

The Eighth District met at St. Louis on November ^

6. W. E. Barstow, M.D., is Councilor. Officers who i
attended include President H. R. Carstens, M.D., De-
troit; Councilors Roy C. Perkins, AI.D., Bay City and
Ray S. Morrish, M.D., Flint; and Secretar}- Foster and
Executive Secretary Burns.

The Fourteenth District is scheduled for November
11 at Ann Arbor, L. J. Johnson, M.D., Councilor. At-
tending officers will include President Henry R. Car-
stens, M.D., Detroit; President-Elect Howard H. Cum-
mings, M.I)., Ann Arbor; Speaker P. L. Ledwidge, M.

I)., Detroit; and Secretary Foster.

The Fifth District is also scheduled for November
11, but at Grand Rapids. Vernor H. Moore, M.D., is
Councilor. Officers who will attend this meeting include ‘
Wilfrid Haughey, M.D., Battle Creek; Editor Roy t
H. Holmes, M.D., Muskegon; R. J. Hubbell, M.D., -
Kalamazoo; Council Chairman Brunk and Executive
Secretary Burns. ■

The Eleventh District plans to meet in Muskegon
on November 21. Roy H. Holmes, M.D., is Councilor. ■
.-\.ttending officers will include Council Chairman A. S.
Brunk, Councilors \'ernor M. Moore, and Wilfrid '
Haughey, Secretary Foster and Executive Secretary
Burns.

The Ni)ith District will meet in Traverse City on
December 5 with Councilor E. F. Sladek. presiding.
Officers at this meeting will include President Henry
R. Carstens, M.D., Detroit; Editor Roy H. Holmes,
Muskegon ; Councilors Barstow and Perkins, Secre- ‘
tary Foster and Executive Secretary Burns.

The Fourth District will meet in St. Joseph on De- .
cember 17. R. J. Hubbell, M.D. is Councilor, \4siting
officers will be Councilors V. M. ^loore, Wilfrid
Haughey, Vice Speaker George H. Southwick of
Grand Rapids, Secretary Foster and Executive Secre-
tary Burns.

The 1941 District Meetings are befiig conducted as
“discussion conferences” with the following important
subjects forming the basis for most of the discussion :
fa) Michigan Medical Service, (b) The M.S.M.S.
Journal, (c) County Society ^leetings, (d) County
Health Units, (e) Ethics, (f) Medical W'elfare.

Jour. M.S.M.S.

854

nestle

COWS' MS' *'
M.iU i..- --

LACTOGEN

approximates
women’s milk in the
proportion of
food substances

Ti

HE cow’s milk used for Lactogen
[is scientifically modified for infant feeding. This
Imodification is effected by the addition of milk fat
and milk sugar in definite proportions. When
[Lactogen is properly diluted with water it results in
a formula containing the food substances — fat, car-
jbohydrate, protein, and ash — in approximately the
Isame proportion as they exist in woman’s milk.

No advertising or feeding
directions, except to phy-
sicians. For free samples
and literature, send your
professional blank to “Lac-
togen Dept.,” Nestle’s Milk
(Products, Inc., 155 East
1 44th St., New York, N. Y.

DILUTED

LACTOGEN

MOTHER’S

MILK

FAT

CARE. PROTEIN ASH

NESTLE’S MILK PRODUCTS, INC

155 EAST 44TH ST,, NEW YORK, N. Y.

"My own belief is, as already stated,
that the average well baby thrives best
on artificial foods in which the rela-
tions of the fat, sugar, and protein
in the mixture are similar to those in
human milk.”

John Lovett Morse, A.M., M.D.

Clinical Pediatrics, p. 156.

November, 1941

Say you ‘taiv it in the Journal of the Michigan State Medical Society

855

READERS’ SERVICE

CARCINOMA OF THE STOMACH WITH PARTICULAR
REFERENCE TO DIAGNOSIS AND RESULTS

The only hope for cure of gastric cancer resides in
recognition of the disease at a sufficiently early stage
to permit its surgical removal. The means whereby
this disease can be recognized, at this stage, when the
opportunity is presented, are within the means of us
all, namely, a carefully taken history, a clear appre-
ciation of the symptoms which may be produced by
early cancer in the stomach, and insistence on compe-
tent roentgenologic diagnosis of the stomach in any
case in which gastric cancer is even faintly suspected.
In addition, an accurate differential diagnosis of any
gastric lesion which either may be or might become
carcinomatous is essential. The benefit of exploratory
laparotomy should be given to any patient who has
gastric cancer, when there is even a small chance that
the lesion might be removed, unless obvious metastasis al-
ready is present. Approximately one-third of the patients
who have gastric resection performed for carcinoma
of the stomach and survive the operation will live for
five or more years following removal of the growth.
Although the ultimate prognosis of gastric carcinoma
is not bright, by increasing effort and diligence on
the part of the medical profession it is hoped that
end results gradually may be Improved. — James T.
Priestley, M.D., Rochester, Minn. (See page 867.)

EFFECT OF ORAL ADMINISTRATION OF
DIETHYLSTILBESTROL ON MENOPAUSAL
SYMPTOMS

The literature on diethylstilbestrol is reviewed
briefly. The author stresses the fact that adequate
therapeutic effect in the majority of menopausal pa-
tients can be obtained from small doses of diethylstil-
bestrol equivalent to 0.5 mg. three to seven times
weekly. The clinical results are similar to those fol-
lowing the administration of the natural estrogens.
Toxic effects appeared in about 7 per cent of the series
of thirty patients treated. He gauged the efficiency of
the drug on subjective evidence alone, the relief of
flushes, rather than the objective evidence as vaginal and
endometrial biopsies and vaginal smears. — J. Wm.
Peelen, M.D., Kalamazoo. (See page 873.)

THE MODERN TREATMENT OF
TRAUMATIC SHOCK

The modern treatment of traumatic shock resolves
itself into a critical evaluation of the clinical patholog-
ical processes taking place which tend to cause a dis-
parity between the volume of blood and the volume
capacity of the vascular tree. This disparity results
from the reciprocal effects of two major factors as
demonstrated by Moon: Capillary atony and tissue
anoxia; either of these factors will cause development
of the other and this reciprocal reaction gives a self-
perpetuating and irreversible circulatory deficiency. Oli-
gemia, hemoconcentration, exemia, anoxemia, acarbia,
acapnia, hyperhydria and hyperpotassiumemia are evi-
dences of the disturbed physiology which can be
corrected by the immediate and intelligent administra-
tion of blood plasma, pectin, adrenal cortex hormone,
concentrated oxygen ; opium derivatives and external
heat are adjunct therapeutic measures. — Henry A.
Hanelin, M.D., Marquette. (See page 876.)

END-TO-END ANASTOMOSIS: MATHEMATICAL
APPROACH TO THE CAUSES OF
MARGINAL GANGRENE

By mathematical analysis is shown that the cut sur-
faces of the bowel lumina, which are to be united by
the usual technique of end-to-end anastomosis, do not
lie in a plane but in a hypoid curve. This curve permits
determination of the relative tension in all parts of the
suture line; the maximum tension being located always
contramesenterially, where pathologists find almost all
marginal gangrenes. It is suggested to cut the bowel
by a method calculated to undo the hypoid. — A. H.
Mollman, M.D., Grand Rapids. (See page 882.)

EXPERIENCES IN PREMARITAL COUNCIL IN
PRIVATE PRACTICE

The purpose of the paper is to give in outline the
general point of view acquired from efforts to meet the
increasing demand for premarital examination and ad-
vice. The somewhat uncertain and unsatisfactory re-
sults often obtained show the lack of satisfactory
knowledge on the subject and the need to give more
time and consideration to premarital examinations.
Girls should be urged to come early rather than late
for premarital council, as the most effective service
often extends over a period of weeks. Contraceptive
advice is given, but planned parenthood is urged as
soon as seems possible to both husband and wife. If
the schools and colleges were to give adequate education
on the subjects of sex and marriage, it would leave
the doctors more time for the technical services which
give the patients the treatment and reassurance that
they need. — ^Richard N. Pierson, M.D., New York.
(See page 884.)

HALF A CENTURY AGO

(Continued from Page 852)

domain of medicine and surgery, and should be studied,
not in a narrow and special manner, but in the broad
light of pathology and medicine. And it is one of the
important signs of progress in dermatology that today
the morbid changes in the skin are almost universally
admitted to be, in very many instances, more or less
intimately associated with, if not the expression of,
deranged systemic conditions.

It is comparatively easy to become familiar with
the dermal affections of external origin. The greatest
difficulty will be found in determining the etiological
factor in cases in which external irritation plays little
or no part. Yet with the increased knowledge of gen-
eral pathology, the improved processes, and facilities
for investigation, patient effort and persistent trial will
discover causes, sometimes obscure, or overlooked by
hasty examination, on which a diagnosis can be made
that goes a long way to ensure successful treatment.

It follows, then, that the general practitioner, who,
by his knowledge of general pathology, is prepared to
diagnose, of necessity should also be well equipped for
the treatment of these cases.

They may not be so numerous in every locality as
to furnish a full clinical assortment, but enough will
be found to illustrate many varieties of dermal dis-
eases, and no class of cases will better repay a careful
study in etiology, pathology and therapeutics, local and
general.

Nearly all are amenable to treatment. No {wtients
are more grateful than those relieved of deformities or
disfiguring diseases. Many of the most unpromising
will be found less intractable than they appear, and to
yield to appropriate treatment, while the hopelessly in-
curable cases, will give credit for accuracy in prognosis,
even if it be unfavorable.

856

Jour. M.S.M.S.

A typical Lederle development

SERUM SICKNESS used to be a serious obstacle to
the successful application of serotherapy. So
great was the fear of these reactions that at times the
patient was even deprived of life-saving treatment.

From 1906 to 1934 the “salting out” method of
serum refining was virtually unchanged. It remained
for Lederle’s staff, long experienced in the problems
of serum production, to establish firmly the value of
a new process of serum refining. This process, based
upon the phenomenon of peptic digestion, removes
up to 90% of the troublesome proteins believed re-
sponsible for untoward serum reactions. Globulin
Modified Antitoxins refined by this method may be
expected to cause a minimum of reactions. They are
higher in potency, smaller in volume and of greater
clarity than previous antitoxins.

But serum refining is only one of many Lederle
biological achievements. Antitoxins, serums, vac-
cines and toxoids from Lederle’s 200-acre serum
farm protect countless individuals from the ravages
of disease all over the world.

November, 1941

5by you saw it in the Journal of the Michigan State Medical Society

857

i

CONVENTION NOTES

CONVENTION NOTES

Michigan newspapers gave 1208 inches in their news
columns, and 70^ inches in their personal columns—
a total of 1278^ inches of space — to the MSMS 76th
Annual Convention, or 11,506^ lines!!! A number
of these stories were first page — and this despite war,
politics, and pretty girls.

^ ^ ^

The larger cities of Michigan were represented at
the 1941 Grand Rapids Convention as follows : Ann
Arbor, 30 ; Battle Creek, 35 ; Bay City, 13 ; Detroit, 201 ;
Flint, 51; Grand Rapids, 194; Holland, 12; Jackson,
28; Kalamazoo, 56; Lansing, 76; Monroe, 7; Mt. Clem-
ens, 2 ; Pontiac, 12 ; Muskegon, 52 ; Port Huron, 7 ;
Saginaw, 35 and Sault Ste Marie, 6. The balance of
those registering came from towns and villages in all
parts of the state.

^

Three Grand Rapids service clubs were addressed
by representatives of the Michigan State Medical So-
ciety on the occasion of the 1941 MSMS Convention.

Wilfrid Haughey, M.D., of Battle Creek addressed
the Kiwanis Club on “Medical Progress,” Alon-
day, September 15 ; L. Fernald Foster, M.D., Bay City,
spoke to the Lions Club concerning “Michigan Medical
Service” on Tuesdav, September 16; and Howard H.
Cummings, M.D., of Ann Arbor addressed the Rotary
Club on “Postgraduate Medical Education,” Thurs-
day, September 18.

* *

M. M. Ricketts, Sales Manager of Petrogalar, flew
from Philadelphia to Grand Rapids, to attend the
MSMS Convention. After spending a day in Grand
Rapids, Mr. Ricketts returned by plane to Philadelphia.

Ted Lewis of Johnson & Johnson came to Grand
Rapids from New Brunswick, N. J. to view the MSMS
Technical Exhibit.

Rubber stamps were used by at least six physicians
who roamed through the exhibits stamping their signa-
tures at the various booths ! ! !

* * *

Speaking of dispensing ; Coca-Cola distributed 3,-
360 bottles at the 1941 MSMS Convention; R. B. Davis
Company served 1,027 glasses of hot pnd f'old Coco-
malt; Philip Morris Company sampled the 2,117 regis-
trants with 9,000 cigarettes ; the klennen Company
distributed 757 bottles of oil and an equal number of
cans of borated powder; the H. J. Heinz Company
dispensed 716 servings of tomato juice; the John Wy-
eth & Brother Company had 448 customers for their
liquid BeWon ; the Kalak Water Company found
587 thirsty customers; and Pet Milk distributed 3,-
507 miniature Pet Milk cans.

Incidentally, 1,280 glasses of beer were enjoyed at
the MSMS Smoker of September 18 (and that’s
quite an incidental).

* * *

The American Society for the Control of Cancer,
Women’s Field Army, entered a scientific exhibit at
the MSMS Convention. This interesting display was
manned by Frank L. Rector, M.D., Field Representa-
tive in Cancer for the MSMS Cancer Control Com-
mittee, as well as by representatives of the Women’s
Field Army of Michigan.

What some of the guest essayists had to say about
the 1941 MSMS Convention:

S'. Wm. Becker, M.D., Chicago: “I believe that the
program presented was one of the best, if not the
best, I have ever seen at a state meeting.”

* *

Robert A. Bier, M.D., Major, National Headquarters,
Selective Service System, Washington, D. C. : “Your

personal and official hospitality, and the kind attention

858

of your Society, endeared them to me, and left a most
favorable impression of my short stay in >'our state.
My only regret is that I was not able to visit with you
longer and enjoy further your splendid hospitality.”

* * *

Janies L, Gamble, M.D., Boston. “I very much en-
joyed my visit to Grand Rapids and wish to express
my sincere appreciation of the courtesy and entertain-
ment which I received. The hospitality offered me
by the members was intensive.”

Chester S. Keefer, M.D., Boston: “You are to be

congratulated on the arrangement and conduct of a
most successful meeting and I feel certain that both
the guests and the members of your Society benefitted
greatly by the meeting. Thank you for a ver\- pleasant
visit to Grand Rapids at the time of your annual ses-
sion.”

* ♦ *

George IV. Kosmak, M.D., New York : “May I take
this opportunity to acknowledge the many courtesies
extended by your members. The meeting was most
enjoyable and the proceedings of great interest and
value. The arrangements for the comfort of your
guests were perfect and I shall always look back with
a great deal of pleasure to my visit to Grand Rapids
in 1941.”

* * *

Charles E. Lyght, M.D., Northfield, Minn. : “The
arrangements before and during my visit to the meet-
ing in Grand Rapids were nothing short of perfect.
I assure you it was a great pleasure to be present and
I want 3^ou to know how much I appreciate the atten-
tive courtesy of my ‘ubiquitous host,’ and the many
others who anticipated my wants almost before I was
aware of them myself. The whole meeting had a dis-
tinctly friendly touch.”

* *

UClliam S. Mengert, M.D., Iowa City, la. : “I would

like to take this opportunity to say that your meeting
was one of the best organized and well managed of
any I have attended, and the hospitality shown me was
superb. It was indeed a pleasure to attend the meet-
ing of the Michigan State Medical Society in Grand
Rapids and to address your General Assembly.”

^ *

H. G. Poncher, M.D., Chicago : “I think your meet-

ing was as well organized as any state medical society
I have ever visited. You have a splendid group to
talk to, and I enjoyed fraternizing with the men. I
had as nice a time as I have ever had at any state
medical meeting.”

* * *

Francis E. Senear, M.D., Chicago: “I enjoyed being

in Grand Rapids very much and felt that the meeting
was conducted in an unusually well organized manner.
I appreciated the opportunity of meeting many of my
old University of Michigan friends on that occasion.”
* * *

V. P. Sydenstricker, M.D., Augusta, Georgia : “I

assure you that my visit to Michigan was enjoyable
in every way. The meeting seemed to me to outclass
any state meeting which it has been my privilege to
attend in the subject matter of the program and in the
interest and earnestness displayed by those attending.
The constant kindness and solicitude of my ubiquitous
host almost shamed me for I know what a serious
interruption I was to his routine. Please express my
thanks to The Council for their kindness and accept
my personal expression of gratitude to you for the
opportunity to attend your meeting.

^ ^ ^

Carroll S. Wright, M.D., Philadelphia: “I do not

think I ever attended a medical meeting where so
much effort was put forth to make the guest speakers
enjoy themselves. I thoroughly enjoyed the annual
meeting of the Michigan State Medical Society.”

Jour. M.S.M.S.

TTu: JOURNAL

of the Michigan State Medical Society

Issued Monthly Under the Direction of the Council

Volume 40 November, 1941 Number 11

Carcmnma of the Stomach

Diagnosis and Results*

[ By James T. Priestley, M.D.

[ Division of Surgery,

Mayo Clinic, Rochester, Minnesota

James Taggart Priestley, M.D.

Rochester, Minnesota

B.A., University of Pennsylvania, 1923;

I M.D., University of Pennsylvania, 1926; M.S.

j in Experimental Surgery, University of Minne-

I sota, 1931; Ph.D. in Surgery, University of

I Minnesota, 1932. Head of a section in the

j surgery division. The Mayo Clinic, Rochester.

I Associate Professor of Surgery, The Mayo

Foundation, University of Minnesota. Fellow
! of the American College of Surgeons.

I Historical Aspect

■ It was Billroth who performed the first suc-
j cessful resection of the stomach for cancer in
1881.® The patient on whom Billroth performed
this operation was a woman named Teresa Haller,

I who had a polypoid carcinoma in the distal por-
tion of her stomach. Approximately a third of
the stomach was removed and gastro-intestinal
continuity was reestablished by the Billroth I
procedure, whereby the end of the stomach is
anastomosed directly to the duodenum. The pa-
tient’s immediate postoperative convalescence was
I without event, and she was dismissed from the
hospital twenty-twoi days following operation.
Unfortunately, the ultimate result was not so
brilliant as the immediate postoperative conva-
lescence, and she succumbed four months later
from what was termed “cancerous degeneration
of the peritoneum.” By 1886 partial gastrectomy
had been performed thirty-seven times for cancer
with a mortality of 73 per cent. The longest
length of postoperative life at this time was one
and a half years. This could hardly be consid-
ered a propitious beginning. However, two im-

*WilHam J. Mayo Lecture given at the University of Michigan,
Ann Arbor, Michigan, April 25, 1941.

portant facts had been established : first, that can-
cer of the stomach could be removed and the
patient survive the operation, and second, that at
least a certain length of postoperative life might
be anticipated following extirpation of a gastric
neoplasm. With courage and firm conviction the
pioneers in gastric surgery gradually developed
this field against very considerable opposition and
many difficulties. Dr. W. J. Mayo’s first con-
tribution to the subject appeared in 1894,^ and by
1910^ he reported 627 operations for gastric car-
cinoma with resection performed in 36 per cent
of cases and a mortality rate of 12 per cent, a
record which would compare not unfavorably
with certain current reports on the subject. Dur-
ing the ensuing years he published many further
reports.

Etiology

Search was first made many years 'ago for the
etiologic factor in cancer of the stomach, but, as
you know, this was unsuccessful. Much of the
work which has been done on this subject has
dealt with possible precursory changes in the
gastric mucosa which might predispose to sub-
sequent malignant change. The possible associa-
tion of certain forms of gastritis with the later
appearance of gastric carcinoma has been stressed
frequently. The inherent difficulty in these stud-
ies involves the unavailability of microscopic
specimens from an appreciable number of stom-
achs in which carcinoma develops at a later date
and also a control group studied similarly in
which malignancy does not develop. Recently
Dr. E. S. Judd^ has completed an interesting
study of this subject in which he found certain
differences between the usual stomach in which
carcinoma is present and the apparently normal
stomach. In the former he observed definite
hyperplasia of the mucous cells, a pronounced
degree of atrophy of the chief and parietal cells.

November, 1941

867

CARCINOMA OF THE STOMACH— PRIESTLEY

1

lymphocytic infiltration and irregularity of the
muscularis mucosa. At times these changes are
noted in the apparently normal stomach but are
usually less marked under these circumstances.
He concluded that carcinoma develops in a stom-
ach damaged probably over a period of years and
that the pathogenesis of gastric malignancy is
associated directly with the disorganized hyper-
plasia of the mucous cells. Whether gastric
cancer can develop on a previously benign gastric
ulcer has been the subject of numerous discus-
sions and will not be considered in detail at this
time. The frequent clinical significance of this
possible relationship, however, will be discussed
later. Virtually all malignant lesions of the stom-
ach are of the adenocarcinoma type as in a recent
study 98.3 per cent were found to be of this type
and only 1.7 per cent were sarcomatous in na-
ture.'^

Diagnosis

From the most recently published statistics it
is estimated that carcinoma of the stomach ac-
counts for 37,000 deaths each year in this country
alone.® Any disease which occurs so frequently
and which has such grave implications should be
of interest to all engaged in the practice of medi-
cine and surgery. Furthermore there is some
evidence to suggest that carcinoma of the stomach
is increasing in frequency or perhaps it is being
recognized more often than previously. At the
present time the only hope for cure of gastric
carcinoma resides in its recognition at a suffi-
ciently early stage to permit surgical removal. In
addition the only current expectation of reducing
the mortality of this disease in the future lies in
establishing the diagnosis earlier in a higher per-
centage of cases so that more patients may be
afforded the possible benefits of gastric resection.
From these facts alone the importance of early
diagnosis is readily apparent. As most of you
will be confronted frequently with the first pre-
requisite of cure for the patient with gastric
carcinoma, namely, recognition of the disease, the
means by which this may be accomplished seem
worthy of emphasis. Those of you who will par-
ticipate in the second essential to cure; namely,
extirpation of the lesion, necessarily will learn
the technical procedures by which this can be
accomplished at a later time during your hospital
training.

How then does one recognize carcinoma of
the stomach in its early stages? At times this
may be extremely difficult or virtually impos-
sible to accomplish for reasons which will be
mentioned. At other times failure to establish
the diagnosis at the most opportune time may
be solely the responsibility of the physician.
Unfortunately, there is no uniform or path-
ognomonic symptom complex which is present
invariably in cases of gastric carcinoma. The
first prerequisite for early diagnosis is a clear
appreciation of the symptoms which may be
caused by early carcinoma of the stomach.
Unfortunately, many textbooks describe only
the symptoms of advanced gastric carcinoma,
at which stage of the disease the patient can
derive little benefit from its recognition.
Several years ago Wilbur® described three
syndromes, one of which usually occurs in the
presence of gastric cancer. A clear apprecia-
tion of these syndromes is most important, I
believe, in the detection of operable carcinoma
of the stomach. The first and most common
is the so-called typical syndrome which usually
is presented by a patient of middle or ad-
vanced age. Commonly the patient has en-
joyed perfect digestion until the rapid onset
of dyspepsia, which almost always is constant
and progressive in nature. This dyspepsia
may vary widely in character and consist of
anorexia, discomfort after meals, belching,
epigastric distress, nausea and perhaps vomit-
ing. As time progresses there may be loss of
weight and strength. A second group of pa-
tients who have gastric carcinoma present the
so-called ulcer type of syndrome. Individuals
in this group may have the “pain-food-ease”
sequence commonly associated with peptic
ulcer for a brief or prolonged period of time.
Because of this fact the danger of instituting
medical treatment on a presumptive diagnosis
of peptic ulcer without the benefit of com-
petent roentgenologic examination of the
stomach is at once apparent. Subsequently
symptoms of this type frequently change in
one of several ways. They may lose their
customary intermittency and become constant
or food may aggravate rather than relieve the
distress. Nausea and anorexia may supervene,
and measures which previously gave relief
may now fail to do so. A third group of pa-
tients who have gastric carcinoma probably

868

Jour. M.S.M.S.

CARCINOMA OF THE STOMACH— PRIESTLEY

afford the most difficult diagnostic problem
as they present a so-called nondescript type of
history and may complain of no symptoms
which immediately direct attention to the
stomach. Under these circumstances one’s
clinical suspicions must be quite readily
aroused if the true diagnosis is to be estab-
lished at an early date. In these cases symp-
toms referable to the gastro-intestional tract
may be vague, indefinite or entirely absent.
They may consist of constipation, bloating,
belching, nonlocalized abdominal discomfort,
and perhaps loss of energy, weight and
strength. Surprisingly often and for no ap-
parent reason, patients of this group may state
that they were in perfect health until an at-
tack of “flu” from which they never fully re-
covered. Only with increasing experience will
the physician at once suspect gastric car-
cinoma in the case in which it is actually re-
sponsible. for this group of symptoms, as of
course these symptoms may be caused by a
variety of other conditions. Whenever an en-
tirely adequate explanation for such symptoms
is lacking, roentgenologic examination of the
stomach should always be performed.

In the diagnosis of gastric carcinoma, as with
other diseases, the orderly sequence of clinical
investigation following a carefully taken and ac-
curately evaluated history requires a thorough
physical examination and subsequently certain
laboratory or other studies. Physical examina-
tion of the patient with cancer of the stomach
may reveal little or much. In the early case
there may be no abnormal findings. In the some-
what more advanced case there may be obvious
loss of weight, anemia, and perhaps a palpable
mass in some portion of the upper half of the
abdomen. In the advanced case evidence of
metastasis ma}^ be noted in the supraclavicular
lymph node on the left side, as stressed by
Virchow. In addition, there may be an enlarged
nodular liver, metastases palpable on digital ex-
amination of the rectum, involvement in the
region of the umbilicus and occasionally else-
where. Such findings are of importance only
by indicating the ultimate futility of operation.
Laboratory studies, including roentgenologic in-
vestigation, are of great value. Blood studies
indicate the presence and degree of anemia and
also dehydration in case vomiting has been a

prominent feature. Gastric analysis may be of
some value in the clinical differentiation of benign
ulcer and actual carcinoma as the values for the
free and the total acidity usually are reduced in
the latter condition and may be elevated in case
of benign ulcer. It is well to remember, how-
ever, that only 50 per cent of cases of gastric
carcinoma are associated with achlorhydria.

Of greatest importance is careful roentgeno-
logic examination of the stomach by a competent
roentgenologist. Of all examinations and investi-
gative procedures utilized at the present time for
the recognition of gastric carcinoma, this is with-
out doubt the single procedure of most usefulness
although gastroscopy in skilled hands is assuming
a role of increasing importance. In any case in
which there is the slightest suspicion of gastric
carcinoma the patient should be given the benefit
of roentgenologic examination of the stomach
despite any inconvenience and difficulty which
this may entail. By this means the diagnosis
will be established earlier in a higher precentage
of cases. During recent years gastroscopy has
been assuming increasing importance in the
recognition of gastric lesions of all types. It ap-
pears possible that in the future this procedure
may become of even greater value. When used
in conjunction with roentgenologic examination
of the stomach, gastroscopy may be of material
aid in the differential diagnosis of gastric lesions
of questionable nature. It is well for the prac-
tical clinician to remember that the gastroscopist
as well as the roentgenologist is only human and
has certain inherent limitations in his examina-
tion and, therefore, may at times be in error. Be-
cause of this fact it is obvious that there is no
substitute for sound clinical judgment in the
correlation and consideration of all the diagnostic
evidence available, including the history and
physical examination as well as the laboratory
data.

Failure of Diagnosis

What factors, then, are primarily responsible
for failure to recognize cancer of the stomach
in its early stage? Why does the true nature of
the disease remain unrecognized in so many cases
until the lesion is definitely inoperable and all
hope of cure is lost? The factors responsible for
this unfortunate occurrence may be divided into
three distinct categories ; first, the so-called “le-
sion factor” ; second, the “patient factor,” and

November, 1941

869

CARCINOMA OF THE STOMACH— PRIESTLEY

third, the factor for which the medical profession
is solely responsible. These three factors will be
considered in order. Unfortunately, symptoms
which may be produced by cancer of the stomach
are dependent to a great degree upon the situa-
tion of the growth within the stomach and the
actual disturbance in normal gastric physiology
which it causes. For this reason a relatively
small growth situated near the pyloric end of
the stomach which disturbs emptying of the
stomach will give rise to symptoms much sooner
than a growth of similar size situated in the fun-
dus or cardia, which causes no appreciable clinical
alteration in gastric function. Lesions in the
latter situation may attain very considerable size,
unfortunately, and even extend beyond the stom-
ach before they cause recognizable disturbance
which directs attention to the stomach. Because
of this fact late diagnosis seems inevitable in a
certain proportion of cases because of the in-
herent nature of the lesion itself. At the present
time there is no good prospect of overcoming this
cause of late diagnosis. In addition, certain
growths which are situated extremely high in the
stomach and perhaps involve also the lower por-
tion of the esophagus, may be inoperable when
first detected, even though they cause symptoms
relatively early in the course of their development.

The so-called patient factor which is respon-
sible for late diagnosis in a second group of cases
has several different causes. Symptoms may be
mild and of little apparent significance at their
onset, and for this reason the patient fails to
consult his physician early in the course of the
disease. An important and perhaps increasing
hazard is the institution of self-treatment by the
patient, which is promoted all too frequently by
commercial advertising of patent remedies or by
well-meaning but misinformed friends and rela-
tives. Again the patient may postpone adequate
medical examination because of social or financial
difficulties. By proper education of the laity, the
medical profession should be able to reduce
gradually this “patient factor” as a cause of late
diagnosis of carcinoma of the stomach.

The third or “physician’s factor” is the one
for which the medical profession is solely re-
sponsible because of failure to recognize the
true nature of the lesion when opportunity for
early diagnosis actually is afforded. There are
of course numerous reasons which may lead to

this failure on our part. Unfamiliarity with,
and therefore failure to recognize, the clinical
picture which may be presented by patients
who have early carcinoma of the stomach is
the cause in some cases. Failure to perform
a thorough and careful physical examination
may permit a small but significant mass in
the upper part of the abdomen to remain un-
detected. Reluctance to secure competent
roentgenologic examination either because of
expense or local unavailability of adequate
facilities may result in postponed diagnosis.
Many roentgenologic examinations of the
stomach with entirely normal findings must be
performed if early carcinoma is to be detected
in a high percentage of instances.

In addition to these obvious factors whereby
we, as practitioners of medicine, may be respon-
sible for late diagnosis, there are certain pitfalls
in the differential diagnosis of gastric carcinoma
against which we must be constantly on guard.
Gastric ulcer probably should be placed first in
this category. Whether benign gastric ulcer may
become during the course of time a true gastric
cancer has been a subject of controversy for
many years and probably will remain so for some
time to come and will not be discussed at this
time. The fact remains, however, that certain
small ulcerating carcinomas may masquerade as
benign lesions both clinically and roentgenologi-
cally. It is because of this fact that virtually
every gastric ulcer must be viewed with suspicion
until it is proved beyond doubt to be benign in
character. If operation is not performed this can
be accomplished only by instituting medical treat-
ment with the patient under close observation and
continuing this treatment until all clinical and
roentgenologic evidence of the ulcer has disap-
peared completely. Furthermore, the patient
should be examined subsequently to ascertain
definitely that recurrence of the ulcer has not
occurred. Any criteria short of these appear in-
adequate to establish the benignity of a given
gastric ulcer with absolute certainty. In this
regard it seems important to emphasize the fact
that although the roentgenologist has a most re-
markable record of accuracy, he is not infallible,
as in a recent study it was found that in 10 per
cent of cases in which resection was performed
for carcinoma of the stomach the roentgenologic

870

Jour. M.S.AI.S.

CARCINOMA OF THE STOMACH— PRIESTLEY

diagnosis was “ulcer.” On numerous occasions it
has been observed that a malignant ulcer in the
stomach may decrease in size roentgenologically
during the course of medical treatment which
reduces the associated inflammatory reaction. For
this reason one must insist on complete disap-
pearance of the lesion before it is considered as
a benign ulcer.

In a certain group of cases a perfunctory diag-
nosis of anemia without satisfactory explanation
may permit a gastric carcinoma to attain in-
operable proportions before its presence is detect-
ed. For this reason roentgenologic examination of
the stomach and, in fact, the entire gastro-
intestinal tract, should be performed in any case
of severe anemia of undetermined cause. Carci-
noma of the stomach may cause profound anemia
without any evidence of gross bleeding from the
gastro-intestinal tract or symptoms which inescap-
ably direct attention to the stomach. At times
what appears to be a simple gastric polyp actually
may be malignant or may become malignant;
therefore, when such a polyp is detected by
roentgenologic or gastroscopic examination it
should not be ignored merely because it is not
considered responsible for symptoms. In many
cases such polyps probably should be treated
surgically when recognized. If for any reason
operation is not performed, periodic subsequent
examination by a competent roentgenologist is
essential and operation should be performed if
there is any growth or other appreciable change
in the physical characteristics of the polyp.
Failure to follow this practice may result in the
development of an extensive gastric carcinoma
before its presence is appreciated. In another
group of cases in which cancer of the stomach
may attain serious extent before its recognition,
patients, usually of middle age or older, appear
clinically to have organic disease perhaps
because of loss of weight and strength, anemia,
anorexia or other symptoms. All methods of
clinical investigation, however, reveal only un-
important findings. We should insist that such
individuals return in six weeks for reexamina-
tion. At this time the true nature of the difficulty
may be detected readily. If left to his own devices
such a patient otherwise may not come back
until a hopelessly inoperable condition has de-
veloped.

Indications for Treatment

After the diagnosis of gastric carcinoma has
been established, what are the indications for
treatment? First of all one always should keep
in mind the hopeless prognosis if the growth is
not removed. In other words, any chance of
removing the lesion cannot be neglected and all
patients should be given the benefit of explora-
tion except in the presence of certain definite
contraindications. Physical examination may
reveal the presence of metastasis which makes
operation futile. Most often this evidence is
found in the left supraclavicular lymph node,
the cul-de-sac of Douglas (as detected in digital
examination of the rectum) or in the liver.
Occasionally metastasis may be noted in the
umbilicus or in inguinal or other lymph nodes.
Only rarely does carcinoma of the stomach
metastasize to the lung.

Roentgenologic examination of the stomach
gives most valuable information regarding the
local extent of the growth, its situation in the
stomach and the likelihood of operability. The
roentgenologist, in addition to detecting a gastric
neoplasm, will often venture his opinion regard-
ing operability of the lesion. Such an opinion by
a competent roentgenologist is quite helpful to
the surgeon and usually accurate. It is well to
remember, however, that the roentgenologist is
limited in his examination and obviously does not
have the same opportunity of determining oper-
ability that is afforded the surgeon at the operat-
ing table. For this reason there will be a certain
degree of error in the roentgenologist’s opinion
regarding operability, and it is important to keep
this fact in mind so that we are not guided in
deciding whether to advise exploration by the
roentgenologist’s report alone but by the clinical
picture as a whole. In a recent study it was noted
that gastric resection was accomplished in 48.1
per cent of cases in which exploration was per-
formed with a roentgenologic diagnosis of an
operable lesion. In addition, the growth was
removed in 23.3 per cent of cases in which
operation was performed after a roentgenologic
opinion of doubtful operability was obtained. Of
particular interest is the group of cases in which
exploratory operation was performed despite the
roentgenologist’s belief that the lesion was in-
operable, as in 14.3 per cent of these cases
resection was achieved. This of course does not
mean that gastric resection was performed in 14.3

November, 1941

871

CARCINOMA OF THE STOMACH— PRIESTLEY

per cent of all cases in which the roentgenologist
diagnosed an inoperable lesion, as in by far the
large majority of these cases the patients were
not even subjected to an exploratory operation.
In the relatively small group of cases in which
an exploratory laparotomy was performed, how-
ever, the growth was removed in 14.3 per cent
of cases. The important point in this regard is
that in the absence of clinical evidence of inoper-
ability the roentgenologist’s interpretation of in-
operability should not always be accepted as a
definite contraindication to exploratory operation.

Results

What results may be expected in the treatment
of carcinoma of the stomach? If one is to de-
termine accurately just what chance for cure the
patient with carcinoma of the stomach actually
has, he must first consider all cases in which the
diagnosis is made, as emphasized by Livingston
and Pack.^ A recent study’^ revealed that the
diagnosis of gastric carcinoma had been made in
10,890 cases at the Mayo Clinic from 1907
through 1938. During this period exploratory
laparotomy was performed in fifty-seven of each
100 cases in which the diagnosis of gastric carci-
noma was made. Gastric resection was performed
in twenty-five of the fifty-seven cases in which
operation was performed, and in the remainder
exploratory laparotomy alone or some palliative
operation was performed. As the average opera-
tive mortality rate for gastric resection during
this period was 16 per cent, this means that only
approximately twenty-one of the twenty-five pa-
tients who underwent resection (out of the orig-
inal group of 100 cases in which the diagnosis
of gastric carcinoma had been made) survived
the operation and therefore had some chance of
ultimate cure. A follow-up study revealed that
29 per cent of patients who underwent resection
and survived the operation lived for five years or
longer and 20 per cent lived for ten years or
longer. This means (29 per cent of the twenty-
one patients who had resection and survived the
operation) that six of the 100 patients whose
condition was diagnosed originally as cancer of
the stomach lived for five years or longer and
that four lived ten years or longer. During
recent years the rates of operability and resect-
ability of carcinoma of the stomach have been
increased somewhat and consequently the ulti-
mate cures correspondingly enhanced.

It must be granted that these figures present
a rather dismal prospect of cure for cancer of
the stomach. Rather than having a discourag-
ing effect, however, these data should stimu-
late us all the more to establish the diagnosis
early in a greater number of cases so that
more individuals can be afforded the possible
benefits of resection. If considered only from
the point of view of those patients who under-
went resection and survived the operation it
is seen that twenty-nine of each 100 patients
survive for five years or longer and twenty live
ten years or longer. Although this survival
rate is comparable with that obtained in the
treatment of malignant lesions in certain other
parts of the body, obviously it leaves con-
siderable to be desired. The important point
to remember, however, is that the patient who
presents himself with a resectable lesion has a
far better chance of surviving five years after
operation than does the average individual
with carcinoma of the stomach.

Study of the factors which influence end
results when resection has been performed indi-
cates that involvement of the regional lymph
nodes and the grade of malignancy are two of
the most important considerations. Thus 62 per
cent of patients with grade 1 or 2 lesions lived
for five years or longer whereas only 27 per
cent of those with grade 3 or 4 lesions lived five
years or more. Unfortunately, approximately
73 per cent of gastric carcinomas are either grade
3 or 4. When the regional lymph nodes have not
been found to be involved 42.1 per cent of pa-
tients lived five years or more following opera-
tion ; however, when involvement of lymph nodes
was present only 17.2 per cent survived for this
period of time. Extension of the growth to near
or distant structures is another factor which
influences ultimate prognosis. When this has
occurred, even though the entire growth ap-
parently is removed, ultimate results are slightly
less favorable. Certain other factors such as
location of the lesion in the stomach, presence
or absence of free hydrochloric acid in the gastric
contents, value for hemoglobin, and so forth
appear to have minor influence on survival rate.

Comment

In closing, I believe we should remember that
the only hope for cure of gastric cancer resides in

Jour. M.S.IM.S.

872

MENOPAUSAL SYMPTOMS— PEELEN

recognition of the disease at a sufficiently early
stage to permit its surgical removal. The means
whereby this disease can be recognized, at this
stage, when the opportunity is presented, are
within the means of us all ; namely, a carefully
taken history, a clear appreciation of the symp-
toms which may be produced by early cancer
in the stomach, and insistence on competent
roentgenologic diagnosis of the stomach in any
case in which gastric cancer is even faintly
suspected. In addition, an accurate differential
diagnosis of any gastric lesion which either may
be or might become carcinomatous is essential.
The benefit of exploratory laparotomy should
be given to any patient who has gastric cancer,
when there is even a small chance that the lesion
might be removed, unless obvious metastasis
already is present. Although the ultimate prog-
nosis of gastric carcinoma is not bright, by in-
creasing effort and diligence on the part of the
medical profession it is hoped that end results
gradually may be improved.

References

1. Judd, E. S.: The possible relation of residual lesions in

the gastric mucosa to the development of carcinoma of the
stomach. Thesis, Graduate School of the University of
Minnesota, 1938.

2. Livingston, E. M. and Pack, G. T. : End-results in the

treatment of gastric cancer; an analytical study and statis-
tical survey of sixty years of surgical treatment. In Pack,
G. T. and Livingston, E. M. : Treatment of _ cancer and

alhed diseases by one hundred and forty-seven international
authors, vol. 2, chap. 69, pp. 1110-1263. New York:
Paul B. Hoeber, Inc., 1940.

3. Mayo, W. J. : Surgery of the stomach. Med. Rec., 46:580-
582, (Nov. 10) 1894.

4. Mayo, W. J. : Radical operation for cancer of the pyloric end
of the stomach: review of 266 partial gastrectomies. Jour.
A.M.A., 54:1608-1612, (May 14) 1910.

5. Priestley, J. T. : The early development of surgical treat-

ment for gastric carcinoma. Proc. Staff Meet., Mayo Clin.,
15:641-645, (Oct. 9) 1940.

6. Vital statistics: Special reports. Department of Commerce,
Bureau of the Census, Washington, D. C., 12:241, (Mar. 13)
1941.

7. Walters, Waltman, Gray, H. K., Priestley, J. T., Lewis,

E. B. and Berkson, Joseph: Malignant lesions of the

stomach: results of treatment from 1907 through 1938

(preliminary report). Proc. Staff Meet., Mayo Clin., 15:625-
638, (Oct. 2) 1940.

8. Wilbur, D. L. : Symptoms and signs which make possible the
earlier recognition of carcinoma of the stomach. Minnesota
Med., 19:728-731, (Nov.) 1936.

= [V|SMS

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BUY CHRISTMAS SEALS

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Tuberculosis

Effect of Oral Administration
of Diethylstilbestrnl on
Menopausal Symptoms

By J. William Peelen, M.D.
Kalamazoo, Michigan

J. William Peelen, M.D.

M.D., Rush Medical College, 1932. Mem-
ber of the Staffs of Bronson Methodist, and
Borgess Hospitals, Kalamazoo. Member, Mich-
igan State Medical Society.

■ The series of investigations begun by Dodds
and his associates on the estrogenic activity
of phenanthrene and dibenzanthracene com-
pounds led to the synthesis in 1938 of the potent
estrogenic substance, diethylstilbestrol.^ The or-
iginal observations of this group of workers, and
many subsequent confirmations by others, have
proved that this substance — though differing in
chemical structure from the natural estrogens —
possessed estrogenic activity equal to, if not more
potent than, some of the natural estrogens. Un-
like the natural estrogens, diethylstilbestrol loses
little or none of its activity upon oral administra-
tion. When assayed by the Allen and Doisy
method 1 mg. of diethylstilbestrol is equivalent to
25,000 international estrone units. Many clinical
studies have confirmed its value as a hormone
substitute, but many of the authors have doubted
whether it was free from danger when given in
therapeutically effective doses.

Diethylstilbestrol is well tolerated in animals
without toxic effects, as are full estrogenic doses
of the natural estrogens. Selye® showed that in
mice and rats diethylstilbestrol — like estradiol —
when given in very large doses produces acute
and chronic toxicity. Both diethylstilbestrol and
the natural estrogen, in doses that greatly ex-
ceeded the estrogenic dose, produced signs of
acute toxicity marked by jaundice resulting from
liver damage, kidney changes, and changes in
other organs. Chronic toxicity was reflected in
a considerable enlargement of the liver. Loeser,®
experimenting with rats, noted loss of appetite,
epistaxis, vaginal and intestinal hemorrhages,
fatty degeneration of the liver with subsequent
necrosis, enlargement of the adrenal glands with
hyperemia and bleeding, and enlargement of the
spleen with hemorrhagic changes in the islands.

Concerning the toxicity of diethylstilbestrol in

November, 1941

873

MENOPAUSAL SYMPTOMS— PEELEN

TABLE I. CLINICAL RESULTS

Diagnosis

Dosage

Total

Amount

Administered

Duration

of

T reatment

Results

Toxic

Reaction

1. N. Menopause

0.3 mg.

10 mg.

3 days

None

Nausea and Vomiting

2. N. Menopause

0.5 mg. every other day

240 mg.

10 mo.

Relief

None

3. N. Menopause
Senile Vaginitis

1.0 mg. daily

80 mg.

7 mo.

Partial

Relief

None

4. N. Menopause

0.5 mg. 4 times weekly

14 mg.

14 days

Relief

None

5. Menstruating

0.5 mg. 2-3 times weekly

50 mg.

6 mo.

Partial

Relief

Slight nausea from
large dosage

6. N. Menopause

0.5 mg. every other day

550 mg.

7 mo.

Partial

Relief

None

7. N. Menopause

0.5 mg. every other day

40 mg.

7 mo.

Relief

None

8. Menstruating

0.5 mg. every other day

64 mg.

4 mo.

Relief

None

9. N. Menopause

0.5 mg. daily

100 mg.

6 mo.

Relief

None

10. N. Menopause

0.5 mg. daily

58 mg.

3 mo.

Relief

None

11. N. Menopause

0.5 mg. every other day

32 mg.

3 mo.

Relief

None

12. N. Menopause

0.5 mg. every other day

60 mg.

3 mo.

Relief

None

13. N. Menopause

0.5 mg. 3-5 times weekly

30 mg.

3 mo.

Partial

Relief

None

14. Menstruating

0.5 mg. daily

14 mg.

2 mo.

None

None

15. N. Menopause

0.5 mg. 4-5 times weekly

34 mg.

2 mo.

Relief

None

16. N. Menopause

0.5 mg. every other day

34 mg.

2 mo.

Relief

None .

17. N. Menopause

0.5 mg. daily

34 mg.

1 mo.

Relief

None

18. S. Menopause

0.5 mg. 5 times weekly

210 mg.

8 mo.

Relief

None

19. S. Menopause

0.5 mg. every other day

60 mg.

8 mo.

Relief

None

20. S. Menopause

0.5 mg. every other day

100 mg.

7j4 mo.

Relief

Slight nausea if dose
is increased

21. S. Menopause

0.5 mg. every three days

62 mg.

6^ mo.

Relief

Slight nausea if dose
is increased

22. S. Menopause

0.5 mg. 5 times weekly

140 mg.

5y2 mo.

Relief

None

23. S. Menopause

0.5 mg. every other day

80 mg.

5 mo.

Relief

None

24. S. Menopause

0.5 mg. every other day

60 mg.

5 mo.

Relief

None

25. S. Menopause

0.5 mg. daily

15 mg.

14 days

None

Nausea

26. S. Menopause

0.5 mg. every other day

20 mg.

1 mo.

Relief

None

27. N. Menopause

0.5 mg. every other day

20 mg.

1 mo.

Relief

None

28. N. Menopause

0.5 mg. every other dav

30 mg.

Ij^ mo.

Relief

None

29. N. Menopause

0.5 mg. daily

30 mg.

1 mo.

Relief

None

30. S. Menopause

0.5 mg. every other day

40 mg.

1 mo.

Relief

None

human beings, investigators have been disturbed
mainly by the possibility of liver damage. How-
ever, no instances of severe toxic jaundice or
deaths have been reported. Payne and Shelton^
performed liver function tests on twenty-six pa-
tients and found all to be within normal limits,
except one in whom hippuric acid secretion had
been high before treatment. The symptoms of
intoxication in this patient (scotomata, nausea,
jaundice, and pruritus) promptly disappeared af-
ter treatment was discontinued. Kidney dam-
age, indicated by the appearance of albumin and
casts in the urine, was observed by Buxton and
Engle^ in one of their patients. The urinary
findings returned to normal after the drug was
withdrawn. MacBryde^ and Sevringhaus® ob-
served no evidence of damage to the liver, kidney
or bone marrow. Mazer^ stated that in ten pa-
tients of his series there occured no changes in
weight, blood pressure, basal metabolic rate, ur-
ine, or blood.

As clinical experience in the use of this drug
increased, it became apparent that the signs of
intoxication that follow the administration of
this drug are probably overdosage phenomena.
In the early clinical studies in which the mini-
mum daily dosage of 5.0 mg. recommended by
the Therapeutic Trials Committee was used, as
high as 80 per cent of the treated patients devel-
oped toxic symptoms. With the employment of
smaller doses (average of 1.0 mg. daily) the in-
cidence of intoxication was greatly reduced.

The criteria used for evaluation of the thera-
peutic activity of diethylstilbestrol have been
the relief of menopausal symptoms plus ob-
jective evidence as supplied by vaginal and en-
dometrial biopsies, vaginal smears, and gona-
dotropic factor levels in the urine. Payne and
Muckle,® relying upon subjective evidence
alone — the relief of flushes — to gauge the ther-
apeutic efficacy and dosage of the drug, showed

Jour. AI.S.M.S.

874

MENOPAUSAL SYMPTOMS— PEELEN

that lower dosages, ranging from 0.1 to 1.0
mg. of the drug daily, were sufficient to relieve
the climacteric symptoms rapidly and efficient-
ly in the majority of their patients. In pre-
scribing medication for the relief of the dis-
tressing symptoms of the climacterium it is im-
portant to keep in mind the individual varia-
tions in the physiologic response to the drug
and the glandular adjustment which is neces-
sary for complete recovery from the meno-
pausal syndrome.

Clinical Observations

The present study apparently confirms the
findings of Payne and Muckle on the effective-
ness of small doses of diethylstilbestrol, as de-
termined by relief of menopausal symptoms.
However, it does not support their contention
that larger doses are required in artificially in-
duced menopause than in the naturally occurring
menopause. Diethylstilbestrol* was administered
by mouth to a series of thirty patients (Table
I) for periods varying from fourteen days to
ten months. At the start of this investigation
the initial dosage was 1.0 mg. daily. This dos-
age was reduced shortly afterward to 0.5 mg.
daily. The latter dosage was prescribed for two
weeks with instructions that the drug should be
discontinued for one day, if nausea developed,
and resumed the next day. The initial dosage
was considered adequate when the menopausal
flushes were held in abeyance. This result us-
ually was obtained within one week. Mainten-
ance dosage was then determined, and in most
I instances was found to vary from three to seven
I 0.5 mg. capsules weekly. No consistent differ-
I ences in the maintenance dosage in surgical and
I natural menopause were noted. One patient who
j received only two weeks of treatment remains
i free from symptoms at the time of this writing,
j six months later. The largest total amount of
; the drug given to any one patient was 240 mg.

I The patient who was given this amount over a
j period of ten months did not develop any signs

1 of intoxication.

I

j Among the patients included in this series was
j one with senile vaginitis who experienced relief
j from hot flushes on a dosage of 0.5 mg. of di-
I ethylstilbestrol daily. However, no improvement

' *DiethylstilbestroI used in. this investigation was supplied

1 through the courtesy of the ‘Medical Division of the Upjohn
Company, Kalamazoo, Michigan.

November, 1941

in vaginitis occurred until the dosage was in-
creased. On a dosage of 1.0 mg. daily for 10
days mature cornified epithelial cells appeared in
the vaginal mucosa, and the inflammation sub-
sided. In three other cases not included in this
report this larger dosage was necessary to pro-
duce objective signs of estrogenic effect as deter-
mined by vaginal smears. Although the number
of observations are too few to warrant the draw-
ing of definite conclusions, they justify the postu-
late that small amounts of the drug are sufficient
for symptomatic relief. When estrogenic effect
on the tissues is desired, however, larger doses
are required.

Toxic Effects

Two of the thirty patients were unable to take
the drug because of nausea and vomiting. These
manifestations appear soon after ingestion of the
drug, and disappeared within twenty-four hours
after its discontinuation. The nausea and vomit-
ing promptly reappeared when diethylstilbestrol
was again administered. Three patients expe-
rienced slight nausea when diethylstilbestrol was
given daily; reduction of dosage to 0.5 mg. two
to four times weekly relieved the flushes without
the appearance of nausea. One patient devel-
oped headaches when taking 0.5 mg. of diethyl-
stilbestrol daily, but had no difficulty when the
same amount was taken on alternate days. On
this lower dosage the patient continued to remain
almost completely free from her previous meno-
pausal symptoms. Vaginal bleeding was not ob-
served with the doses of diethylstilbestrol used
in this study. In some of the patients the drug
exerted a mild laxative effect.

Summary and Conclusions

Adequate therapeutic effect in the majority of
menopausal patients can be obtained from small
doses of diethylstilbestrol, equivalent to 0.5 mg.
three to seven times weekly. The clinical re-
sults are similar to those following the admin-
istration of the natural estrogens. Nausea and
vomiting appeared in about seven per cent of the
series of thirty patients treated. These side ef-
fects disappeared promptly upon discontinuance
of the drug. Small doses of diethylstilbestrol
will produce satisfactory relief of symptoms in
most of the menopausal patients ; but when histo-
logic evidence of estrogenic effect is needed, as

875

TRAUMATIC SHOCK— HANELIN

in senile vaginitis, larger doses of about 1.0 mg.
daily appear to be required.

136 E. Michigan Ave.

Bibliography

1. Buxton, C. L., and Engle, E. T. : Jour. A.M.A., 113:2318,
(December) 1939.

2. Dodds, E. C., Lawson, W., and Noble, R. L. : Lancet,
1:1389 (June 18) 1938.

3. Loeser, A.: Ztschr, f. d. dges. exper. Med., 105:430,

(April) 1939. Klin. Wchnschr., 18:346, (March 11) 1939.

4. MacBryde, C. M., Freedman, H., and Loeffel, E. : Jour-
A.M.A., 113-2320, (December) 1939.

5. Mazer, C.: Jour. C)bst. and Gynec., 40:138, (July) 1940.

6. Payne, F. L., and Muckle, C. W. : Jour. Obst. and

Gynec., 40:135, (July) 1940.

7. Payne, S., and Shelton, E. K. : Endocrinology, 27:45,

(July) 1940.

8. Selye, Hans: Canad. Med. Assn. Jour., 41 :48-49, (July)
1939.

9. Sevringhaus, E. L. : Jour. A.M.A., 114:685, (February

24) 1940.

^=Msms__

The Modern Treatment

of Tranmatic Shock""

Henry A. Hanelin, M.D.

M.D., University of Illinois College of Medi-
cine, 1934. Attending Surgeon at St. Mary’s
Hospital, and Associate Attending Surgeon at
St. Luke’s Hospital, Marquette. Member,
Michigan State Medical Society.

By Henry A. Hanelin, M.D.
Marquette, Michigan

■ The recent impetus to the study of shock has
been more or less promulgated by the advent of
World War II ; however, important observations
and deductions were elicited during World War
I. A number of investigators®’^’®’^^’^^’^^’^®’^®’^®
formulated a basis for future studies regarding
the mechanism and treatment of shock. Due
credit must be given to the various British,
Canadian, and American scientists who have
brought forth certain observations which have
helped to clarify some of the various mechanisms
concerned in the mechanism of shock.

Blalock^ states “shock is an all inclusive term
which denotes a disturbance in the circulation
that is characterized by a diminution in the venous
return of blood to the heart. This holds true,
in general, because the heart itself is not at fault
and is able to propel the blood that returns to it.
The diminution in the venous return usually
results from a decrease in the ratio of the volume
of blood in circulation to the capacity of the

*Presented before a joint meeting of the Marquette-Alger,
Delta-Schoolcraft, Dickinson-Iron County Medical Societies.
Symposium on Intestinal Obstruction and Shock. March 25,
1941.

vascular tree, due to a decrease in the volume of
circulating blood or to an increase in the capacity
of the vascular bed or both.” From this state-
ment one gathers that the relative expansion and
decrease of the peripheral vascular bed is due to
certain toxic factors which disturb the relative
tonus of the more or less elastic osmotic mechan-
isms which tend to maintain certain normal re-
lationships between the circulating blood volume
and the peripheral vascular and tissue spaces.

Cowell® reemphasizes the fact that wound
shock is a condition of failure of the circulation
in that failure of the circulation gives rise to a
drop in blood pressure, reduction of the body
temperature, diminution of the blood volume and
concentration of the blood, intracellular anoxemia,
and, in untreated cases, subsequent death.

Cressman and Blalock^® state that all cases of
shock are not referable to one etiology and various
classifications have been devised to distinguish
them. Thus primary and secondary shock have
long been used. Primary shock refers to the im-
mediate collapse following injury as contrasted
with secondary shock which comes on after a
variable interval following the trauma.

Primary shock has usually been interpreted as
the immediate reaction of the nervous system to
trauma, similar to ordinary syncope, initiated by
a peripheral vasodilation, probably in the splanch-
nic area with a sudden fall in blood pressure,
leading to unconsciousness. Primary shock often
merges imperceptibly into secondary shock.
Blalock^ has suggested a physiologic classifica-
tion on the basis of acute circulatory failure, the
different types being designated as hematogenic,
neurogenic, and vasogenic. Hematogenic refers
to those instances in which there is an initial
decrease in the blood volume which is followed
by a compensatory vasoconstriction and a de-
crease in the output of the heart and subsequently
by a decline in the blood pressure. The conditions
associated with simple hemorrhage and trauma to
the muscles are examples of this type. The
neurogenic type is associated with vasodilation
which is dependent on diminished constrictor
tone as a result of influences acting through the
nervous system. The blood pressure declines
first and subsequently there is decrease in the
blood volume and the cardiac output. The vaso-
genic type is associated with vasodilation which is
produced by agencies which act directly on the
blood vessels and capillaries ; histamine probably

876

Jour. M.S.M.S.

TRAUMATIC SHOCK— HANELIN

CLASSIFICATION OF SHOCK

Type

Cause

Pathologic Physiology

Hematogenic
Secondary Shock
Gravis Type

1. Hemorrhage

2. Excessive Trauma

3. Burns

4. Difficult Obstetrical
Labor

Tissue response to excessive trauma
“Blalock”

(Hemoconcentration or dilution depending on relative
losses of whole blood and plasma)

1

Injury Local loss Decrease in Decrease ven-

to — of whole — blood volume — ous return and

tissues blood and and blood flow cardiac output

plasma to tissues

Vasoconstrictions ) Further decrease — Vasodilatation

Decrease blood pressure 3 blood volume
Tissue anoxia — General capillary dilatation
and increase in permeability

Neurogenic

Primary Shock
(Syncope)

1. Trauma to Viscera

2. Spinal Anesthesia

3. Postural Hypotension

4. Carotid Sinus Irrit-
ab'lity

1. Trauma to mesentery causes a general decrease in vascular
tone and reflex inhibition of the heart through the vagus
nerve.

2. Primary alteration is vasodilation on diminished constrictor
tone as a result of influences acting through the nervous
system.

Vasogenic

1. Histamine

2. Nitrites

3. Addison’s Disease

Direct action of toxic agencies on blood vessels.

exerts most of its effects in this manner. Un-
fortunately, no one type of shock is usually
present, since the interrelationship of the various

! or noxious factors present.

Grodins an^Freeman^^ state that the following
‘ changes in the blood and circulation are generally
agreed upon as occurring in traumatic shock;

1. Capillary stagnation, which leads to reduction of
the effective blood volume (oligemia), as evidenced
by :

a. Hemoconcentration.

b. A decrease in venous return to the heart with a
resulting reduction in cardiac output.

c. A decrease in circulating blood volume by
exemia.

2. Decreased tone of skeletal muscles, decreased arter-
ial pressure, collapsed veins, and depressed respira-
tion.

3. Anoxemia.

4. Decrease in the alkali reserve (sodium bicarbonate)
of the blood (acarbia).

5. Partial compensation for the tendency to acidosis
by a reduction in the carbonic-acid content of the
blood (acapnia).

6. An actual decrease in the pH of the blood
(acidemia or hyperhydria), which results because
of the fact that there is only partial compensation
for the acidosis.

7. A rise in the plasma potassium, which is interpreted
as an indication of a disturbance in cell perme-
ability.

Moon^* states that circulatory failure of capil-
lary origin results from a disparity between the
volume of blood and the volume capacity of the
vascular system. That disparity results from the
reciprocal effects of two major factors, capillary
atony, and tissue anoxia. Either of these factors
will cause development of the other, and this
reciprocal reaction gives the circulatory deficiency
a self-perpetuating quality which tends toward an
irreversible condition. This tendency tow'ard ir-
reversibility requires early recognition and action,
and early studies will reveal hemoconcentration.
The circulatory deficiency which results from
capillary atony is accompanied by a group of
characteristic visceral pathologic changes. These
are capillo-venous congestion in the thoracic and
abdominal viscera, edema of the soft tissue (such
as lungs and mucosa) effusion into serous cavi-
ties, and petechial hemorrhage in parenchymatous
organs, in serous and in mucous surfaces.

Cannon® states that a prolonged low blood
pressure is attended by a deficient supply of
oxygen to the tissues ; undoubtedly nerve cells are
peculiarly sensitive to a lack of oxygen, and there-
fore persistence of the state of shock may result
ultimately in the loss of vasomotor tone, with
resultant exhaustion of the nerve cells due to a
relative anemia.

November, 1941

877

TRAUMATIC SHOCK— HANELIN

Selye, Dosne, Basset, and Whittaker^^ ob-
served that animals exposed to various damag-
ing agents responded with a syndrome of an
“alarm reaction,” and that this alarm reaction
consists of two phases; the first of which is
the phase of shock, characterized by loss of
muscular tone, decrease in body temperature,
decrease in blood volume with transudation of
plasma into the tissue spaces, anuria, a rapid
fall in blood chlorides and often also in blood
sugar, hemorrhages into the gastro-intestinal
tract, and other changes, all of which are
generally accepted as typical of shock. During
this stage the organism is obviously damaged
and many experimental animals die. The
duration of this shock phase depends on the
severity of the agent used and on the resistance
of the animal, and varies between one and
thirty-six hours in the rat.

Immediately following this stage an entirely
different set of symptoms appear which might
descriptively be referred to as “countershock.”
During this second phase the most outstanding
morphological changes are marked enlarge-
ment of the adrenal cortex, severe atrophy of
the thymus and to a lesser degree of other
lymphatic organs. Most of the changes char-
acteristic of shock have not only disappeared
but are actually reversed during the counter-
shock period. Thus the blood chlorides and
the blood volume tend to rise above normal,
diuresis is excessive, and the temperature rises.
Since adrenalectomized animals are unable to
develop a clear-cut countershock response and
at the same time show a very low resistance
against damaging agents, and since the adren-
als reveal obvious signs of increased activity,
especially during the countershock phase of
the alarm reaction, they concluded that the
adrenals play an important role in shock de-
fense.

Their investigations in the rat indicated how-
ever that in traumatic shock the adrenals always
show characteristic changes. The cortical cells
discharge their lipid granules (probably the
carriers of the cortical hormones) and become
greatly enlarged. Mitotic proliferation of these
cells is likewise not uncommon, and as a result
of these changes the weight and size of the glands
are greatly increased. The adrenal medulla loses
its chromaffin granules, which is taken to indicate

that it discharges adrenalin into the blood. These
changes were observed following all types of
surgical injuries, such as excessive muscular
excercise, exposure to cold, or treatment with
toxic doses of various drugs, the adrenals show
the same histologic changes as are seen in cases
of trauma. Following all these injuries the more
the adrenals enlarge, the more pronounced is the
thymus involution. This led them to conclude
that excessive adrenal activity and thymus in-
volution are both parts of the same general
defense reaction against damage, namely, the
“alarm reaction.” The fact that in adrenalecto-
mized animals, which develop all other signs of
shock very readily, the thymus fails to involute
during exposure to stress and strain gave further
support to their contention that the adrenal en-
largement and the thymus atrophy are counter-
shock phenomena. The question arose, however,
what part of the adrenal is essential for shock
defense? Cannon’s well known work on the
emergency secretion of adrenalin during exposure
to damage made it rather likely that this hormone
is the one which is primarily involved in counter-
shock phenonema. Certain other facts known at
that time pointed in the same direction. Thus
Kellaway and Cowell noted that in adrenalec-
tomized cats, which are very sensitive to hista-
mine, resistance against this compound is greatly
improved by adrenalin administration. However,
as Selye et al. have shown, overdosage with
adrenalin will initiate a subsequent shock state
and lethal doses of adrenalin fail to cause
thymus involution in the adrenalectomized rat,
while cortin given in sufficiently large doses is
effective in this respect. It is further observ^ed
that the toxic effects of adrenalin are counter-
acted by cortin in the adrenalectomized rat. These
experiments confirmed their belief that it is
primarily an increased adrenal cortical secretion
which is responsible for the development of
resistance in the countershock phase.

They also showed that cortin antagonized both
insulin hypo-glycemia and adrenalin hyper-
glycemia in the rat which furnished another proof
that cortical hormone acts as a “stabilizer” of
metabolic processes even in the non-adrenalec-
tomized animal.

The fact that cortical hormone therapy exerts
beneficial effects in so many different conditions
makes it rather likely that the hormone is not a
specific antidote in any one of these cases but

878

Jour. M.S.M.S.

TRAUMATIC SHOCK— HANELIN

raises shock resistance in general because a con-
dition of relative “adrenal insufficiency” exists
in organisms exposed to nonspecific damage.
The clinical observations concerning the curative
action of cortin in surgical shock likewise ap-
peared to point in this direction, but in patients
suffering from shock cortin has so far never been
used without the simultaneous administration of
other therapeutic agents, and no animal experi-
ments have yet been published on the action of
cortin in surgical shock.

Treatment

From the above review of current literature it
is quite obvious that the treatment of traumatic
shock resolves itself into a rectification of the
disturbances which are associated with a pro-
found vasomotor and cellular disfunction, name-
ly: hemoconcentration, anoxemia, acarbia, acap-
nia, and oligemia.

Minot and Blalock’^’' state that the transfusion
of blood plasma is probably the method of choice
for the restoration of plasma volume. The use
of plasma rather than whole blood avoids further
burdening of the circulation with cellular ele-
ments which are already present in high concen-
tration. Volume for volume plasma transfusions
introduce protein approximately twice as fast as
when whole blood is given.

Scudder,^^ Swingle, Parkins, Taylor, Hays,^“
Reed^^ and Corrado^^ have shown that the mere
replacement of glucose and electrolytes in trau-
matic shock is ineffective in controlling the mor-
bid symptomatology unless massive doses of
adrenal cortex hormone are given intravenously,
subcutaneously, and in certain cases orally. The
adrenal cortex homone seems to be essential in
stabilizing not only the electrolytes but also in
maintaining the normal oncotic relationship be-
tween the carbohydrates and proteins of the tis-
sue spaces.

Reed^^ calls attention to the fact that serum
potassium is elevated during shock and that this
increase is proportionate to the severity of the
shocked condition of the patient; this fact being
previously emphasized by Scudder. He further
shows that the administration of adrenal cortex
hormone is helpful in controlling the coagulabil-
ity of the blood.

Ravdin^° showed that in the presence of hypo-
proteinemia attempts to restore a normal fluid
and electrolyte balance without at the same

time increasing the colloid osmotic pressure by
adding to the plasma protein too frequently re-
sults in adding to the extravascular fluid re-
serves. Therefore, it would seem logical to sum-
marize the various beneficial effects of plasma
transfusion at this time as a corrective measure
in overcoming hypoproteinemia and hemoconcen-
tration.

Silverman^^ and Katz^® have beautifully sum-
marized the indications for plasma transfusion
and state that plasma besides being given in-
travenously can be given per hypodermoclysis and
intramuscularly when the condition of the pa-
tient is such that the accessible veins cannot be
readily reached, and that the rate of absorption
is an individual matter but roughly approximates
that of physiological saline.

Physiological Properties of Plasma

Plasma is essentially the liquid portion of
blood separated without clotting, while serum is
the liquid portion remaining after clotting has
taken place. Plasma may be considered a liquid
solution of three important proteins, albumin,
globulin, and fibrinogen. The total protein con-
tent of normal plasma may vary from 6.5 to 8.5
Gm. per 100 c.c.

Plasma is the ideal physiological fluid for the
maintenance of blood volume. The red blood
cells abstracted from the plasma are in no way
effectual in exerting any colloid osmotic pressure.
This is the function of the plasma proteins, and
it is this property which makes possible the use-
fulness of stored plasma in those emergencies
where blood pressures have fallen to a dangerous
state. The fleeting effects of the electrolytes,
glucose, and adrenalin as measures of overcom-
ing shock are well known.

The hemostatic effect of citrated plasma prob-
ably resides in its several protein fractions,
fibrinogen, platelets, and prothrombin content.

Types of Available Plasma

At present there are two types of plasma being
used, the wet and the dry. Wet plasma is de-
fined as the liquid plasma separated from im-
clotted blood and is either unmodified or diluted
with saline or glucose. By dry plasma is meant
plasma which has been subjected to various dry-
ing procedures and finally put up as a powder
for ultimate regeneration with distilled water
when needed.

November, 1941

879

TRAUMATIC SHOCK— HANELIN

Medical Indications For Plasma

A. Gastro-intestinal Conditions

1. Nutritional edema and hypoproteinemias

(a) Exogenous

(b) Endogenous

2. Hemorrhagic gastro-intestinal states

(a) Hemorrhagic gastritis

(b) Bleeding gastric or duodenal ulcer

(c) Ulcerative lesions of the large intestine.

3. Postoperative obstruction complicating gas-
tric surgery

4. Infections

(a) Bacillary dysentery

(b) Peritonitis following a ruptured viscus

B. Nephritic and Nephrotic States.

1. Anurias

C. Cardiac States

Surgical Indications For Plasma

A. Shock.

1. Primary

2. Secondary

B. Dehydration

C. Burns

D. Wound healing and wound disruption

E. Increased intracranial pressure

F. Postoperative pulmonary atelectasis and edema

G. Pre-anesthetic preparation of bad risk liver

To determine from a therapeutic standpoint whether
blood plasma or salt is indicated, three fundamental
procedures must be carried out :

1. The determination of the number of red blood
cells per c.mm.

2. The relative volume as determined by the hemato-
crit. This is obtained by centrifuging a constant
quantity of blood to a constant volume and calculat-
ing the ratio of the volume of packed cells to
plasma. The hematocrit in men varies between 43
to 50 per cent, and in women from 38 to 43 per
cent.

3. Estimation of the total blood proteins is made
through an indirect method of determining the
specific gravity of the blood plasma.

Wherever possible the above information should be
elicited as a guide to therapy ; with constant repeti-
tion until the patient is in normal balance.

Oxygen Therapy In The Treatment Of Shock

As has been shown in the preceding discussion,
anoxia is one of the most important symptoms of
the deficiency state seen in traumatic shock, and
as Aub and Cunningham^ have shown, traumatic
shock causes a marked slowing of the blood flow
and a marked decrease in the oxygen content of
the venous blood from an average of 12.3 vol-
umes per cent to 4.8 vols. per cent. There is an
associated reduction of the oxygen content in the
arterial blood from an average of 17.2 vol. per

cent to 12.8 vol. per cent. Boothby, Mayo, and
Lovelace^ have shown that the inhalation of
oxygen not only results in an increase in the
oxygen in chemical combination with hemoglobin,
but in a substantial increase in the amount of
oxygen in physical solution in the blood plasma.
They show that :

“The amount of oxygen in 100 c.c. of arterial blood
of the average normal individual will be increased
from 19.5 c.c. when the individual is inhaling air to
22.2 c.c. when he is inhaling 100 per cent oxygen. That
is, there will be an increase from 10 to 15 per cent in
the oxygen content of the arterial blood. At first
thought, this 10 to 15 per cent increase appears to be
comparatively small and possibly negligible. That this
increase is not immaterial, however, depends on anoth-
er factor ; namely, the rate at which the blood is
circulating through the tissues. The blood as it passes
through the capillaries gives up to the tissues, under
normal circulatory conditions, only about 40 per cent
of its load of oxygen ; the venous blood, therefore, is
still about 60 per cent saturated, and the average partial
pressure of oxygen in the capillaries will correspond
to approximately 35 mm. of mercurj' (effect of carbon
dioxide neglected). If for any reason the rate of cir-
culation is decreased, as occurs for example in shock,
the blood may give up as much as, or even more than,
80 per cent of its load of oxygen as it passes slowly
through the capillaries ; therefore, the venous blood is
only 20 per cent saturated and will exert a pressure
equivalent to approximately 14 mm. instead of 35 mm.
of mercury. Now, if nothing else is done but to cause
the patient to inspire 100 per cent oxygen, instead of
the 21 per cent of oxygen contained in the air, the
arterial blood which leaves the lungs will contain, as
has been shown, 2.2 c.c. more oxygen per 100 c.c. In
consequence the capillary and venous blood which
leaves the lungs will contain from 10 to 15 per cent
more and will be 33 per cent saturated instead of 20
per cent saturated. There will be a corresponding
increase in the partial pressure of oxygen in the
capillaries, from 14 to 21 mm., which is the equivalent
of a 50 per cent increase in the pressure of oxygen in
the tissues.”

These authors also point out the role of a
moderate elevation of the body temperature in
increasing the arterial oxygen content.*

Summary and Conclusion

In recapitulation of the pathological physiology
that is present when a state of traumatic shock
ensues, hemoconcentration, tissue anoxia and
hypoproteinemia associated with degenerative
changes in the suprarenal glands both in the
cortex and the medulla are the paramount dis-

*Since this paper was presented Schnedorf and Orr=" have re-
emphasized that the inhalation of a high concentration of oxygen
is indicated in the treatment of traumatic shock.

Jour. M.S.M.S.

880

TRAUMATIC SHOCK— HANELIN

turbances which must be rectified before irrevers-
ible changes occur.

1. The immediate administration of the
adrenal cortex hormone intravenously or sub-
cutaneously should be started as soon as the pa-
tient is admitted to the receiving room and not
one-half hour or an hour later after the patient
has been admitted to the surgical service, where if
it is necessary the dose may be repeated. (Com-
pound dosage of adrenal cortex hormone is usual-
ly necessary.)

2. The practical advantages of plasma over
whole blood transfusions in the treatment of
traumafic shock are :

(a) There is no need to type the patient. Time
is therefore saved and the plasma can be actually
running into the vein within five minutes of the
patient’s admission to the hospital.

(b) The plasma can be kept in liquid form for
long periods without deterioration.

(c) There is no need for elaborate refrigera-^
tion.

(d) Plasma is equally effective in the treat-
ment of transfusions for hemorrhage as whole
blood is. The loss of red cells from the body is
unimportant unless it is accompanied by sufficient
loss of plasma to reduce the blood volume.

3. Administration of high concentrations of
oxygen to overcome the tissue anoxia should be
started as soon as the patient is admitted in the
state of shock.

4. The application of external heat to con-
serve the body temperature is essential since
most patients admitted in traumatic shock have a
vasoconstrictor type of circulatory failure.

5. The intelligent use of the stimulating and
pain relieving drugs is very essential and here-
with are listed the therapeutic armamentarium
available in the treament of the various phases of
traumatic shock :

(a) For the type of peripheral circulatory fail-
ure in which vasodilation is an early prominent
feature the use of a number of vasoconstrictor
drugs has been recommended ; among those
which have been recommended are ; epinephrine,
ephedrine, caffeine, neosynephrin hydrochloride,
ether, strychnine, coramine, cardiazol benzedrine,
pitressin, paredrin, paredrinol, camphor.

(b) Morphine is excellent for the prevention
or the relief of pain and restlessness, and contra-
indicated where intracranial injuries are sus-
pected.

(c) Papaverine hydrochloride, spasmalgen,
and insulin-free pancreatic extracts may be used
where the prominent feature of the peripheral
circulatory failure is vasoconstriction.

I

6. The modern treatment of shock is therefore
limited to the introduction into the body of a
metabolic stabilizer; namely, adrenal cortex hor-
mone, and the reestablishment of the osmotic
pressure disturbances in the tissues by the ad-
ministration of plasma and oxygen.

Addendum

Recently Henry N. Harkins in an article entitled:
“Treatment of Shock in War Time,” [War Medicine,
1 :520-535, (July) 1941] reemphasized that shock is a
progressive vaso-constrictive eligemic anoxia and that
treatment resolves around this definition.

Due to the limited amounts of plasma available and
the prohibitive cost to the patient at times, various
substitutes are being used with the same beneficial effects
as those exerted by blood plasma, namely the use of
0.5 per cent pure pectin solution [Hartman, F. W. ;
Schelling, Victor ; Harkins, Henry N. ; Brush, B. :
Pectin solution as a blood substitute. Ann. Surg., 114:
212-225, (Aug.) 1941] and isinglass or fish gelatin which
is prepared from the sounds or swimming bladders of
various species (sturgeon, hake, sea trout, et cetera)
[Taylor, N. B., and Waters, E. T. : Isinglass as a
transfusion fluid in hemorrhage. Canadian Med Jour.,
44:547-554, (June) 1941]. — The Author.

Bibliography

1. Aub, J. C., and Cunningham, T. D.: Am. Jour. Physiol.,
54:408, 1920.

2. Blalock, Alfred: Shock or peripheral circulatory failure.

South. Surg., 7:150, (April) 1938.

3. Blalock, Alfred: Principles of Surgical Care, Shock and

Other Problems, pp. 91-173. St. Louis, Mo.: C. V. Mosby
Co., 1940.

4. Boothby, W. M., Mayo, C. W., and Lovelace, W. R. :
Jour. A.M.A., 113:477, 1939.

5. Cannon, W. B.: Traumatic Shock. New York: Appleton

and Co., 1923.

6. Cannon, Walter B.: A consideration of possible toxic and

nervous factors in the production of traumatic shock.

Ann. Surg., 100:704, (October) 1934.

7. Cannon and Bayliss: Gr. Brit. Med. Res. Comm. Rep.,
26:19, 1919.

8. Cornioley and Kotzareff: Rev. de chir.. Par., 59:233, 1921.

9. Cowell, E. M. : The prevention and treatment of shock.
British Med. Jour., 1:883, (April 29) 1939.

10. Cressman, Ralph D., and Blalock, Alfred: Shock. A con-

sideration of prevention and treatment. Am. Jour. Surg.,
46:317, (Dec.) 1939.

11. Crile, G. W.: Surgical Shock and Shockless Operation

^ Through Anoci Association. Philadelphia: Saunders, 1920.

12. Corrado, Pietro: Adrenal cortical hormone in surgery.

Med. Times, (April) 1941.

13. Grodins, F. S., and Freeman, S. : Traumatic shock. Surg.,
Gynec., and Obst., 72-1; Int. Abst. of Surg., Surg. and the
Basic Sciences, 1-8, (Jan.) 1941.

14. Mclver, M. A., and Haggart, W. W. : Traumatic shock:

Some experimental work on crossed circulation. Surg.,
Gynec. and Obst., 36:542, 1923.

(Continued on Page 888)

November, 1941

881

END-TO-END ANASTOMOSIS— MOLLMANN

End-to-End Anastnmasis

Mathematical Approach to the
Causes of the Marginal
Gangrene

By Arthur H. Mollmann, M.D.

Grand Rapids, Michigan

Arthur H. Mollmann, M.D.

University of Heidelberg, Cand. M., Uni-
versity of Munich. M.D., University of Wtwz-
bwrg, 1920. From 1931 to 1939 every summer
\p\ost graduate work in Germany or Austria.
Diplomate of National Board, Washington,

1937. Member of Gertnan Surgical Society,

Western Michigan Trio logical Society and
Michigan State Medical Society.

■The success of an end-to-end intestinal anas-
tomosis is dependent upon asepsis, adequate
blood supply, and a smooth approximation of
the serosa.

A disastrous marginal gangrene in the suture
line of an end-to-end anastomosis prefers in
most cases the contramesenterial area. Concern-
ing the causes of gangrene, pathologists gen-
erally classify defective blood supply as the first,
and bacterial toxins as the second factor of im-
portance. While it has long been known, that
the difficulties of maintaining asepsis in surgery
upon the intestinal tract run parallel with the
abundance of putrefactive bacteria, and therefore
increase greatly towards the large bowel and the
rectum, the question of blood supply deserves
special consideration in the development of a
marginal gangrene.

A mathematical analysis is proposed giving
evidence of undue tension of the suture line
in the contramesenterial area as a necessary
result of our usual technique of end-to-end
anastomosis, leading to a localized anemia in
that portion of the suture line, where most of
the marginal gangrenes are observed. At the
end of the mathematical analysis two meth-
ods are offered to remedy the situation.

Anatomical considerations are the basis of the
usual technique of anastomosis. The arteries in
the intestinal wall take their origin from the mes-
enterial arcades and run perpendicular to the
line of mesenterial attachment and parallel to
each other around the lumen in such a manner
that only very fine branches and capillary anas-

tomoses are found on the contramesenterial area
and between the parallel arteries. Therefore a
longitudinal incision exactly in the contramesen-
terial line does not bleed, and an exact transverse
incision bleeds very little. In the large intestine
this vascular pattern is complicated by the fact
that the arteries in the relaxed bowel wall form
loops in the appendices epiploicae which are very
easily caught by the sutures (Fig. 1).

Schmieden: Surgical Technique.)

These considerations are the main reason for
cutting the bowel not exactly transverse, but at
an oblique angle, so that an accurately placed su-
ture line cannot obstruct the main arteries feed-
ing the contramesenterial area. In spite of this
precaution a marginal gangrene in most cases
prefers the contramesenterial area. It is occa-
sionally observed in small bowel anastomosis but
much more frequently in the case of large bowel
anastomosis. An interference with the arterial
loops in the appendices epiploicae by the suture
line does by no means explain all marginal gan-
grenes in the large bowel, because these loops
may be found in good shape.

Therefore the following explanation is offered.
It is a peculiar physical fact that a round tube —
as for instance the human intestine — which be-
tween clamps in a flattened condition has been
divided by a straight but oblique cut, will not
find its cut surface in a mathematical plane but
in an “S” shaped or hypoid curve, after the tube
has been permitted to take its original round
form (Fig. 2). This “S” shaped curve may be
easily demonstrated by cutting a paper tube in
the described manner and viewing the cut surface
from the side.

It appears that this hypoid curve is of more
than academic interest to the surgeon because

882

Jour. M.S.M.S.

END-TO-END ANASTOMOSIS— MOLLMANN

he usually does not anticipate the degree of
“skewness” of the curve, when he cuts the flat-
tened bowel in the described manner. That is
from the mesenteric attachment to the contra-
mesenteric border in a straight but oblique line,
removing more tissue from the contramesenteric
area, with the view of securing an adequate blood
supply to the cut surface and of decreasing the
stenosing effect of the suture technique which

Bo'wel

Fig. 2. (Left) Flattened bowel, cut at angle of IS degrees.
(Right) Rounded bowel, showing hypoid curve.

folds the entire cut surface inward at least 5 mm
all around. During the time that the bowel con-
tents are permitted to expand the lumen to its
normal round shape, the hypoid curve develops
along the suture line, which of course expresses
itself as tension in the contramesenterial area due
to the elasticity of the bowel wall. Near the mes-
enteric attachment the reverse process takes
place, the cut surfaces being pushed together with
the same force. With an average diameter of
small intestine of 30 mm. and an oblique cut of
about 75° (15° less than a transverse cut) the
hypoid curve develops a tension in the contra-
mesenteric area which is equivalent to the tension
of a gap of 4.6 mm. width. An oblique cut of
70° produces a gap of 6.2 mm. With an average
diameter of 50 mm. in the case of large bowel
and an oblique cut of only 80° (10° less than
transverse) a gap of 5 mm. width develops.

Obviously the tension in the suture line ap-
proximating the contramesenteric serosa surfaces
is greater than in any other portion of the suture
line, though all sutures may have been laid with
exactly the same tension. Merely rounding out
the lumen of the bowel without any particular
gas pressure is responsible for the hypoid curve.
But as the gas pressure becomes excessive, the
disproportion between the tension in the contra-
mesenteric area and the tension in the rest of the
suture line increases greatly. The elasticity of the
bowel wall in the contramesenteric area becomes
exhausted, and the excessive gas pressure will
tend to straighten out the angulation of the bowel
at the point of anastomosis in the same manner.

as for instance water pressure will straighten out
a kinked garden hose. Therefore the maximum
tension always will be found in the contramesen-
teric area, resulting in interference with the blood
supply. Since only small arteries and mostly cap-
illaries are found in this area, the blood pressure
there is correspondingly lower and the flow more
easily interfered with. For these reasons the
rather mathematical hypoid curve may well serve
as one of the factors in the development of mar-
ginal gangrene. It explains the preference of the
marginal gangrene for the contramesenterial area
in the absence of other adequate causes.

The mathematical evidence of the foregoing
statements may be analyzed as follows ;

This formula proves that the cut surface of the
inflated bowel does not lie in a plane, but in a
curve which is symmetrical to the given ordinate.
The character of the curve may be analyzed by
the first derivative.

November, 1941

883

PREMARITAL COUNCIL— PIERSON

I

s

At the contramesenteric border the variables
take the value

xr

X = r and y = — tg

2

dx

while the tangent takes the value — — infinity.

dy

Therefore, the tangent becomes parallel to the
contramesenteric border, proving the hypoid
character of the curve.

The turning point of the curve does not need
to be determined by equating the second deriv-
ative to zero, because its coincidence with the
y axis is too evident. The tangent in the turning
point of the curve is arrived at by

dy

y (limes = 0) and — == tg 9
dx

This tangent meets the mesenteric or contra-
mesenteric line of the inflated bowel at r tg 9
Therefore, the gaping (or tension) between two
obliquely cut bowel lumina at the contramesen-
teric line will be twice

xr

(— tg? — rtg9)

2

or rtg9(x — 2)=1.14rtg9

Examples :

r of small bowel = 15mm, 9 = 15°, gap = 4.6mm
r of small bowel = 15mm, 9 = 20°, gap = 6.2mm
r of large bowel = 25mm, 9=10°, gap = 5mm

Conclusion

This mathematical analysis also makes avail-
able two methods to remedy the effect of the
hypoid curve. The one is to cut the flattened
bowel, as usual, in a straight but oblique line
from the mesenterial attachment to a point about
1 cm. to 1.8 cm. from the contramesenteric bor-
der, from this point the line curves rather sud-
denly to an almost transverse direction (Fig. 3).

Fig. 3. (Left) Flattened bowel, cut by suggested curve.
(Ri^t) Rounded bowel, hypoid curve does not develop in con-
tramesenterial area.

The distance of 1 cm. to 1.8 cm. is an average
and has been calculated from the hypoid curve,
and depends mainly from the diameter of the
bowel. An accurately placed suture line will not
be able to obstruct the main arteries feeding

the contramesenterial area, the stenosing effect
of the suture line will be decreased, no hypoid
curve and no gap will occur at the contramesen-
terial area, and near the mesenteric attachment
the cut surfaces will be pushed together. Evi-
dently the suture technique of a curved surface
can be solved readily by the “open technique of
anastomosis.” The different devices of “aseptic
anastomosis” cannot be readily applied, though
they are not impossible.

The second method calls for a decompression
of that portion of the bowel that has been anas-
tomosed. The hypoid curve cannot develop and
cannot do any harm, as long as the bowel tube
is not rounded out by the pressure of its con-
tents.

Experiences in Premarital
Cnnncil in Private Practice

By Richard N. Pierson, M.D.

New York City

Richard N. Pierson, M.D.

A.B., Princeton University; M.D.,

College of Physicians and Surgeons,

Columbia University, 1918; Formerly
Attending Gynecologist atid Obstetrician,

The Sloane Hospital for Women, New
York. Fellow, American College of
Surgeons, New York Obstetric Society.

Consulting Gynecologist and Obstetrician
Stamford Hospital, Stamford, Conn.,
and Huntington Hospital, Huntington,

L. I.

■ The purpose of this paper is to give in broad
outline the general point of view that I have
acquired from my efforts to meet the increasing
demand for premarital examination and advice in
private practice. It is doubtless your experience,
as it is mine, that the demand for this service has
increased markedly in the last ten years. Thus
I share with you the many doubts and difficulties
that I have experienced in these efforts, rather
than give you statistical analyses of case histor-
ies, and well established conclusions as to the
precise manner in which these problems should
be handled, and the exact techniques that should
be observed in their treatment.

I have had the good fortune for several years
of belonging to a round table group of specialists
in various fields of medicine, together with non-
medical students of the problem, organized under
the National Committee on Maternal Health with

884

Jour. M.S.M.S.

PREMARITAL COUNCIL-PIERSON

the guidance and direction of Dr. Robert L.
Dickinson and Dr. Raymond Squier. This group
has met regularly throughout the winter months,
and we have had the advantage of discussing in-
formally many of the problems that have to> do
with marriage relationships. My reaction to
these meetings, my experiences in practice, and
my study of the now rather voluminous litera-
ture, have all combined to impress me with the
importance of the problem, with our lack of
satisfactory knowledge about it, and, as one
would expect, under these circumstances, the
somewhat uncertain and unsatisfactory results
obtained in handling these cases.

After all, our medical experiences in this field
of medicine have been of short duration. The
first courses on marriage were started at the
University of North Carolina at the request of
the students in 1924, under President Henry W.
Chase and Professor Ernest R. Groves. I can
give you no better perspective on the problem
than to quote from the preface of Professor
Groves’ book, “Marriage.” In describing the
origin of these courses at the University of N. C.
he says :

“The course has not been a series of popular lectures
but a serious study of marriage in all its aspects. The
content of the course has not only reflected the needs
and desire of the students year by year, but also the
reactions and suggestions of those who have taken
it and have later married. If it were within the power
of parents and teachers to retard sex maturity until
the individual was both economically and biologically
prepared to marry, there would be less need of a col-
lege course attempting to anticipate domestic experi-
ence. Nature, however, has given us no choice, and
there is no possible barrier to sex interest which any
educational organization can erect for the shelter of
its youth. The policy that attempts this is incompatible
with the prevailing conditions of modern life and
merely means surrendering the opportunity for con-
structive, wholesome instruction, leaving the young
man and woman to draw information from those who,
however sophisticated and confident, are fundamentally
as ignorant as their pupils. . . . Even in discussing mat-
ters that are not at present controversial, an attempt
has been made to impress upon the student the rapidity
with which new knowledge is appearing, and the tenta-
tive character of many of our present ideas relating
to the marriage adjustment. Anyone who has become
familiar with the literature concerned with marriage
and sex problems, realizes how recent and how faint
and elementary has been the attempt of science to un-
derstand these supremely important phases of human
experience.”

November, 1941

I am sure that your experience agrees with
mine, that the doctors’ problem is made difficult
because the young men and women who come to
us for premarital examination and advice are too
often unready for marriage, both from the point
of view of education and of character. This is
the fault of all of us as parents, and of the edu-
cational programs of our schools and colleges that
are only just beginning to follow the lead of men
like Professor Groves. Because this whole edu-
cational problem seems to me so' important for
us doctors to understand, I wish to quote from a
paper entitled “A Cooperative Project in Mar-
riage Counseling” by Emily H. Mudd, director
of the Marriage Council of Philadelphia and
Bernice Lundein, Secretary. This appeared in
the August number of Human- Fertility.

“We may grant that there are limitations to any
educational process in which the individual is attempt-
ing to learn about facts and attitudes which have strong
emotional content, and in which he has, as yet, had
little experience. May we also grant, however, the
power of knowledge and of talking things over with
someone who has lived these experiences, to lesson
fears implanted by false information and ignorance?
It is through this last mentioned process, in the opinion
of some of us, that courses on marriage and family
relationship can best meet the need of those who take
them.”

The course developed by Dr. Mudd and her
associates comprises a six weeks’ course of five
lectures.

It is important to point out that the course of
lectures is built up on the basis of actual ques-
tions asked by the women themselves. In that
way the first and most important principle of
teaching is observed; namely, interest.

I think it would be of interest to you to know
the subject matter of the five lectures of the
Philadelphia Marriage Council Course :

1. Relationships between single men and women
(leading to marriage).

2. Anatomy and physiology.

3. Physiology of menstruation.

Normal pregnancy.

4. A few abnormalities of pregnancy; the problems
of venereal disease and abortion.

5. Physical relationships of marriage.

Birth control, uses and abuses.

Enduring love and marriage as a lasting institu-
tion.

885

PREMARITAL COUNCII^PIERSON

In commenting upon this course of lectures, Dr.
Mudd makes the following observation :

"The time interval between talks seemed to be valu-
able, not only because of the value of supplementary
reading, but because time is a great safety valve when
emotional processes are involved. The same results
could hardly be obtained by having six talks in one
week. ... It should be noted that the reading of books
about sex can be an upsetting and fearsome experience
to an inadequately prepared or unusually anxious in-
dividual. The opportunity to talk over questions raised
by reading is of paramount importance.”

Premarital Council in the Office

I have given at considerable length the point of
view and the plan of teaching that experts like
Dr. Mudd and Dr. Groves have evolved, to con-
trast it with the service that we doctors are ex-
pected to give to individual young women in the
space usually of one office appointment shortly
before marriage. It is little wonder that such
service tends to be unsatisfactory to the patient
and to the doctor. A recent case of my own may
illustrate the point. I am sure that many of its
aspects will sound all too familiar to those who
practice gynecology and obstetrics.

The patient is the young daughter of rich parents,
recently married to a young lawyer who is making a
small income. She consulted a gynecologist for pre-
marital and contraceptive advice. She is a hypersensi-
tive, small woman, brought up by her mother to be
afraid for her health. She apparently was told by my
colleague to use a contraceptive jelly alone for birth
control purposes. She promptly became pregnant. Be-
cause of an unreasoning fear of pregnancy based on
her mother’s over-solicitude, rather than upon any
medical opinion as to her health, she made every effort
by the use of castor oil, quinine and so forth to bring
about a miscarriage. I first saw her when she was
two and one-half months pregnant, at which time she
was bleeding and having uterine cramps. With ex-
pectant treatment she survived this threat. During the
fourth month, however, she started to flow again and
finally, at five months, had spontaneous rupture of the
membranes and eventually spontaneously expelled a
dead fetus.

During the last two weeks of her pregnancy the par-
ents had requested consultation repeatedly and demand-
ed active interference in the pregnancy to protect their
darling daughter. Fortunately, all consultants agreed
that conservative and expectant treatment was the
only proper course to follow. The first doctor was
blamed most strongly for giving ineffective contracep-
tive advice. I was blamed for my conservative plan
of treatment, both with the threatened miscarriage and
with the later premature labor. The point that I am

trying to make is, that the whole disastrous medical ex-
perience was the result primarily of the poor education
and upbringing of the patient. The mother had con-
ditioned her to the idea of poor health and a fear of
pregnancy. I am sure that the patient was unable to
cooperate sufficiently with the first gynecologist to get
any real benefit from his single attempt to help her.
With me, she was really an intelligent and cooperative
patient, but lost all independence and self-control when
her high-powered mother and father were at hand. I
might also point out what a distorted point of view
toward any subsequent pregnancy she must have ! It
will take much education, reassurance and weaning from
her parents to protect her future childbearing.

Another case history of a patient seen just
this week may offer some points of interest.

In contrast to the girl last described, this young
woman was well adjusted to the whole world. She had
been given a foam powder sponge method of contra-
ceptive which she had found difficult and unpleasant
to use. Two months after marriage, having gone a
few days over her period, she consulted a young doc-
tor as to whether or not she was pregnant. He told
her that she probably was pregnant because of sugges-
tive physical signs, and offered to do an Ascheim Zondek
test. He also laid down an extraordinarily strict regime
for her to follow throughout her pregnancy which great-
ly discouraged her. A few days later her period came.
She consulted me as a gynecologist for reassurance
about the condition of her pelvic organs. Having got-
ten this history from her, I naturally offered her con-
traceptive advice, and then learned that she had made
an appointment with an excellent woman doctor in New
York for that purpose for later the same afternoon !
In other words, our patients do not know to which of
us to turn for advice along these lines.

Another patient, forty-two years old, recently came to
me planning to be married four days later. She had
never read any books on marriage and had gained no
accurate information from family or friends. She was
a college graduate and remembered vaguely some funda-
mental courses on physiology. Examination disclosed a
moderately tight hymen which admitted one finger with
difficulty. She was advised to have a dilatation of the
hymen under gas which she promptly accepted. She
was advised not to use contraceptives because she
and her husband-to-be wanted children. This girl is
an example of an exception to the rule, for she was in-
telligent and cooperative enough to make a last-minute
adjustment which will probably develop into a success-
ful marriage relationship in spite of almost complete
lack of specific education along these lines.

Considering the case histories just described,
and the general observations that preceded
them, do you not agree with me that we must
plan to take much more time with our pre-
marital examinations than has been the cus-

886

Jour. M.S.M.S.

PREMARITAL COUNCII^PIERSON

tom? I think we must tell our colleagues and
educate our friends and patients to the idea
that these girls should come to us, not one or
two weeks before marriage, but any time after
puberty, and certainly early in an engagement.
This would enable the patients to do collateral
reading and allow the doctor time to gain their
confidence, give them reassurance, and meet
any physical problems that may exist. Ex-
perience seems to show that it is desirable for
the same doctor to see both the girl and her
fiance. These consultations are time-consum-
ing and cannot easily be fitted into the busy
office hour. As a matter of fact, most of these
girls would much prefer to see the doctor at
some time when the office was not full of other
women, some of whom might know them.
From this standpoint, an hour outside of regu-
lar office hours would be desirable. Incidental-
ly, one would hope that we might teach our
patients that such unusual, time consuming
and all-important services might be properly
compensated. Many American parents will
gladly pay thousands of dollars for an elabo-
rate wedding when they will balk at the cost
of medical service which may easily make all
the difference in their daughter’s happiness
and adjustment to marriage for the rest of her
life.

Prevention of Dyspareunia

While of course there are many aspects of the
premarital examination that might be gone into,
I am going to limit myself to the discussion of
the prevention of dyspareunia and to the provi-
sion of contraceptive advice.

It has been my experience that the psyche of
the patient is more likely to determine the occur-
rence of dyspareunia than is her anatomy.
Those women are of course excepted who have
a very small or tight hymen. The selfish,
spoiled girl, the hypersesthetic, will have vagin-
isms and severe dyspareunia sometimes, even
if the tissues are soft and open. Other girls
who have been accustomed to taking the world
in their stride with a smile, may have a relatively
small hymen which perhaps may admit only one
finger with some difficulty; these girls may, if
time permits, be dilated slowly in several office
visits, or may be taught to dilate themselves ; or,
if time does not permit and they so choose, go
into marriage with a small hymenal orifice, know-

ing that they will have at first moderate pain
which they will quickly forget. To these girls
no psychic injury will be done. In my experi-
ence, it is best to advise dilatation of the hymen
under gas whenever the hymen is tight, if there
is no time for the slower methods, but if these
girls do not wish this and go into marriage know-
ing what to expect, there will be no harm done.

To go back to the spoiled and pain dreading
girl : if the hymen is small and rigid, a partial
crescentic, posterior excision and dilatation un-
der anesthesia should be done. But no assurance
should be given the parents that such a patient
may not have dyspareunia anyway. The prob-
lem then becomes a psychological and educational
one rather than a medical one.

In any case of continuing dyspareunia, it is
well to remember the numerous points on the
psychic side as enumerated by Groves:

1. Disgust with sex

2. Fear of pregnancy

3. Dislike of contraceptives

4. Instinctive tendency in some women to inhibit the
expression and appearance of passion.

5. Feeling of guilt because of some past experience,
either real or imaginary, having to do with sex re-
lationships

6. Conscious homosexual tendencies

7. Realization that the motive for marriage was dis-
honest ; that is not for love but for money, social posi-
tion, et cetera

8. Instinctive hostility on the part of some women
to the idea of masculine dominance

While on the subject of dyspareunia I should
like to give you an observation which may be
of some interest. It was my opportunity for
several years after being resident at the Sloane
Hospital for Women to perform the autopsies
on the newborn under the direction of Prof.
William C. Johnson. I noted at that time that
I never examined a female baby that did not
have an open hymen. I have still never seen a
newborn baby with any of the many types of
partially imperforate hymen found among adult
women. The other day one of my patients
brought me her three-year-old daughter who had
sat down on some sharp object and caused a
superficial laceration of the perineum. On exam-
ination of the introitus I found the posterior half
of the hymen agglutinated in the mid line, leaving
only a very small opening above. I was able very
gently with a probe to divide the agglutination

November, 1941

887

PREMARITAL COUNCIL— PIERSON

and restore the normal open hymen. It seems to
me probable that all the different types of imper-
forate hymen are acquired during infancy and
childhood. It is of some interest that this little
girl did not mind the examination in the slightest.
Perhaps if our pediatric colleagues would sub-
ject all little girls to routine gentle examinations,
when they become adults they would not be so
terrified of vaginal examinations, and also they
would not have constricted hymenal openings.

Contraceptive Advice

Groves has said, “Most men and women, when
they marry, have the will to succeed.” So also,
I think it is the experience of all of us in our
premarital services to find that our patients,
practically without exception, want to have chil-
dren. But they don’t want them at once. They
usually say that they want them in either one or
two years. Now it seems to me it is perfectly
right for them to wish to plan that first preg-
nancy. I try to persuade them, however, not to
fix on any arbitrary time of waiting, but to know
that in general the sooner they have their first
child, provided both parents are reasonably
secure in health and means, the better off they
will be. Someone has said that there is no con-
venient time for death, taxes and childbirth !
They must be told that even though both husband
and wife seem to their doctors to be entirely
normal, that pregnancy does not always occur
quickly and easily. These young patients must
be taught that neither they nor their doctors are
wise enough to give them perfect and happy
marriage on demand, universally effective and
agreeable contraceptive measures, and a baby on
any day of the month that they may choose. Too
many of them think that this is so !

It seems unnecessary and undesirable to go into
detail about contraceptive techniques. A small
percentage of girls, in my experience, can
be comfortably fitted with a diaphragm before
marriage. Others, if they wish maximum pro-
tection, are urged to have the husband use a
condom and contraceptive paste. If they are
willing to accept a moderate risk of pregnancy,
they are advised to use a contraceptive paste
alone or a suppository alone. With whatever
method, it is important to impress on these pa-
tients that they must return for a follow-up ex-
amination and advice, at which time changes in

technique are advocated if desirable. Otherwise,
mistakes are sure to occur, the patient is disap-
pointed and dissatisfied, and the doctor is criti-
cized and loses a patient.

Summary

In summarizing this paper, I hope that I have
suggested to you the importance of supplying the
education which our young people have demand-
ed, and so much need, on the subjects of sex and
marriage. If our schools and colleges fulfill their
function in this respect, the technical ser\dces of
doctors will become enormously more effective.
For the present, doctors themselves should, I
think, take more time with their patients in order
to give them the reassurance and treatment that
they need. Patients should come early rather
than late for their premarital examinations, as
the most effective service often extends over a
period of several weeks. Contraceptive advice is
given, but planned parenthood is urged as soon as
seems possible to husband and wife. Finally, in
closing, may we doctors hope that through our
efforts and those of our many collaborators in
other fields of society, the words of the old fair}’
tale may be more true in the future than they
have been in the past — “And so they were mar-
ried and lived happily ever after.”

r=|V|SMS

TRAUMATIC SHOCK

(Continued from Page 881)

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17. Minot, A. S., and Blalock, Alfred; Plasma loss in severe
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21. Reed, Fred Romer: Acute adrenal cortex exhaustion and
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22. Reed, Fred R. : Natural adrenal cortex extract and coagula-
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hormones in traumatic shock and allied conditions. Can.
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888

Jour. M.S.M.S.

Medicine Marches Forward

The Proceedings of the MSMS House of Dele-
gates appear in detail in this issue of The Journal.
To epitomize the forward thinking of the 111 Dele-
gates is to outline a few of the many activities of the
MSMS House of Delegates at the 1941 session;

1.

3.

4.

5.

6.

7.

Modernizing the MSMS Constitution and
By-Laws

Recommending the rehabilitation of rejected
selectees

Renewing the MSMS Charter for another
thirty-year period of activity
Creating a Section on General Practice
Adopting the reports of the twenty-three
MSMS committees

Electing progressive practitioners of medicine
(men in daily practice) to the various MSMS
offices

Registering a vote of confidence in Michigan
Medical Service.

Michigan Medical Service, the voluntary group med-
ical care plan sponsored by the Michigan State Medi-
cal Society, was the subject of a number of resolutions
and much discussion. The matter of studying the pos-
sibility of a limited liability certificate was referred to
the membership of Michigan Medical Service for con-
sideration. Such studies are being made, with a view
to distributing medical service to the people of Michi-
gan on a basis mutually satisfactory to them and to
the medical profession.

President, Michigan State Medical Society

■S?-

November, 1941

889

1

-K EDITORIAL >^

IN THESE HANDS

■ At the meeting of the House of Delegates in

September Howard H. Cummings of Ann
Arbor was elected President-elect. For a num-
ber of years he has served the Michigan State
Medical Society on various committees and on
The Council. Last year he was Vice Chairman
of The Council. His keen, calm judgment and
delightful personality combined with a deep and
earnest interest in the welfare of his colleagues
marks him for his outstanding caliber for the
chief executive office of the Michigan State Med-
ical Society. He has been associated with Dr.
J. D. Bruce in the direction of postgraduate med-
ical education in Michigan and the success of this
program has been in no little measure due to his
intelligent administration and his well-deserved
popularity.

A. S. Brunk was rejected Chairman of The
Council that his unusual executive ability and
his sound views on the practice of medicine might
continue to serve the profession.

Vernor Moore of Grand Rapids was retained as
Councilor of the Fifth District representing Bar-
ry, lonia-Montcalm, Kent and Ottawa Counties.
He was also rejected Chairman of the Finance
Committee of The Council demonstrating the
confidence of The Council in his continuing ac-
tivity as the “watch-dog of the treasury.”

Wilfrid Haughey of Battle Creek was again
chosen Chairman of the Publications Committee
following a year in which much of the activity
and progress of the state society and the Michigan
Medical Service have been due to his direction
and assistance.

E. F. Sladek of Traverse City was continued as
Chairman of the Committee on County Societies.
His coordination of the activities of the various
component units of the state medical society has
continued to strengthen the Michigan State Med-
ical Society.

Otto O. Beck from the Fifteenth District was
elected to succeed Dr. Cummings as Vice Chair-
man of The Council. His judgment and keen
interest in medical progress rounds out an Ex-
ecutive Committee of unusual strength and sig-
nificant qualities of leadership.

C. E. Umphrey of Detroit was rejected
Councilor of the First District of Detroit. He
had been appointed last year to fill the vacancy
which occurred when Henry R. Carstens became
President-elect. Dr. Umphrey has continued to
sustain his previous reputation as a stalwart de-
fender of organized medicine which began in his
Wayne County Medical Society activities.

R. J. Hubbell of Kalamazoo was elected Coun-
cilor of the Fourth District. He had been ap-
pointed in November, 1939, to fill the unexpired
term of F. T. Andrews. His capable administra-
tion has won the support of delegates of his dis-
trict and the respect of the other Councilors.

R. S. Morrish was reelected Councilor of the
Sixth District. He had been appointed Councilor
of the Sixth District on January 15, 1940, to fill
the unexpired term of I. W. Greene, who had re-
signed. His able service on The Council has
been recognized in this short time.

Lester J. Johnson of Ann Arbor was chosen
for the office of Councilor from the Fourteenth
District vacated by the resignation of Howard H.
Cummings. Dr. Johnson received his B.S. from
the University of Michigan in 1923 and his M.D.
in 1925. He has been very active in the Washte-
naw County Medical Society, having been Chair-
man of the Public Relations Committee and Dele-
gate from 1938 to 1941. Last year he served as a
member of the Public Relations Committee of the
state society. His progressive views and enthusi-
astic desire for advancement of medical organi-
zation are well known. All the delegates believe
that he will well serve the profession of the state
in this new office.

P. L. Ledwidge, of Detroit, was elected Speak-
er of the House of Delegates succeeding Dr.
O. D. Stryker, of Fremont. Doctor Ledwidge
graduated from Wayne University College of
Medicine in 1920 and after an internship at
Harper Hospital and a residency in Medicine at
Children’s Hospital and Harper Hospital he be-
came associated with the late Dr. E. W. Haass in
the private practice of internal medicine until
1925, since which time he has been alone in pri-
vate practice. He is a Fellow of the American
College of Physicians and Diplomate of the

890

Jour. M.S.M.S.

EDITORIAL

Howard H. Cummings, M.D.,
Ann Arbor, President-Elect

Wilfrid Haughey, M.D., Battle Creek,
Chairman of the Publication
Committee

C. E. Umphrey, M.D., Detroit,
Councilor, First District

November, 1941

A. S. Brunk, M.D., Detroit,
Chairman of The Council

Otto O. Beck, M.D., Birmingham,
Vice Chairman of The Council

E. F. Sladek, M.D., Traverse City, Vernor Moore, M.D., Grand Rapids,
Chairman of the County Societies Chairman of the Finance Committee
Committee

EDITORIAL

American Board of Registration in Internal
Medicine. At present he is Associate Physician
Inside Staff of Harper Hospital and Assistant
Professor in Clinical Medicine at Wayne Univer-
sity College of Medicine. He is a member of the

%

■ V

N

L. J. Johnson, M.D., p. p. Ledwidge, M.D.

Ann Arbor, Councilor, Detroit, Speaker

Fourteenth District House of Delegates

Detroit Medical Club and the Detroit Academy
of Medicine. He has been a delegate to the
Michigan State Medical Society for a number of
years and has taken a very active interest, having
served as member and chairman of several im-
portant committees. His activity in organized
medicine in Wayne County is well known and his
keen interest and analytic ability will be invalu-
able on the Executive Committee of The Council
of which he becomes a member.

The members surely will realize the safety of
their future in such efficient and trustworthy
hands. With active cooperation by the member-
ship the state society may well continue its ag-
gressive program.

= [V[SMS

THE DOCTOR COMES SECOND

■ “Hospitals are provided for the sick and their
doctors, not the sick and the doctors for the
hospital.” With these words Miles Atkinson, in
the Atlantic Monthly, summarizes the oft for-
gotten fundamental reason for the maintenance
of a hospital. In this piercing expose of pro-
fessional relationship the major contention pre-
sented is the relationship of the patient to the
hospital, which justly is the primary consider-
ation.

Mr. Atkinson criticizes the inefficiencies of the
hospital, particularly in a financial manner, and
then condemns the hospitals’ habit of charging
for the physicians’ service which is given free.

Generally the larger the city and the larger the
hospital the more abuse to the physician exists.

Your Birthright for a Mess of Pottage

It is of interest to the profession to deter-
mine what steps the physician may take to free
himself from the bondage of certain hospital
administrators. A part of the “mess of pot-
tage” is the closed staff. Unquestionably the
doctor frequently has sold his “birthright” of
independence in the establishment of the
closed staff for he has made his position on
the staff more important (in his own eyes, at
least) than his inter-professional cooperation,
which should have been guaranteed by virtue
of his medical training.

All have seen the beginning and the end of
the enmeshing of the doctors into the web of
hospital domination. The young man enters the
staff in order that he may have the association
with medical leaders of his community and, in
the larger centers, the postgraduate experience
in the free and part pay clinics. He sees some
of his elders and teachers who may wield more
or less dictatorial powers in hospital relation-
ships, oftimes to the absurdity of having in-
cluded upon every scientific paper produced in
that particular hospital or clinic the name of this
“Little Caesar.” What a cheap way to achieve
professional recognition !

The sacrificing doctor after a year or more
becomes promoted with a high-sounding title
and the privilege of doing more free work and
contributing more time. And as he gives more
time and becomes more involved in this web he
realizes that he has sacrificed his independence ;
he is now definitely associated in his colleagues’
and patients’ minds as an “X” hospital man and
he fears the consequence should he rebel against
a superintendent’s vagary since the staff man
well knows there are many others who are just
waiting to step into his position of honor and
travail, willing to go sled length to attain this
position. The story is an old one.

The trustees of Hospital A are told that the
staff men of their hospital are serving five thou-
sand patients a year in their clinics while Hos-
pital B is serving only three thousand. Tycoon
A, who is Chairman of the Board of Hospital
A, twits his business competitor B, Chairman of
the Board of Hospital B, who comes raving and

892

Jour. M.S.M.S.

EDITORIAL

ranting into the next board meeting demanding
that Hospital B must next year have seven thou-
sand in its clinics. The word goes to the super-
intendent and then to the Chief of Staff and
then down. Occasionally even paid advertising is
used to fill up vacant clinics.

The medical director of one prominent part pay
clinic maintains a standard fee of twenty-five
dollars for consultation in his private practice.
On his staff are some hundred capable specialists
whose established fees are from five to twenty
dollars but when a patient of the director cannot
afford to pay the twenty-five dollar fee which is
exacted by him he refers the patient directly to
his clinic in which his colleagues donate their
services and the patient is charged fifty cents or
one dollar.

Abuses like this could be cited ad infinitum
but what is the solution? There is only one
solution, and that is organized medicine. This
organization must be strongest in its smallest
unit — the county medical society. If the coun-
ty medical society is the basic power of the
profession in the district and if one’s main
medical attachments are founded on that so-
ciety, the physician will not be exploited either
by the hospital or by any other development.
It is almost axiomatic that the stronger the
local medical organization the more satisfac-
tory the standards and the conditions of prac-
tice in that county and this is true in the
largest and the smallest societies.

The term “member of the county medical so-
ciety” should mean more than membership on
the staff of any hospital and when it does the
private practice of medicine will be assured for
all.

Reference

Atkinson, Miles : The Patient Conies First. Atlantic Monthly,
August, 1941.

= [V|SMS

READERS’ SERVICE

■ Beginning with this issue, The Journal is

inaugurating a new service. It has been the
practice to send abstracts of the articles pub-
lished in this journal to the editors of the other
state journals in order that they may use them
when and where desired to keep their readers
informed as to scientific articles published in
Michigan.

Now these digests will be published in The
Journal of the Michigan State Medical So-
ciety,

The general grade of the scientific articles
received and printed has been universally high
and complete reading of each essay is strongly
recommended to the progressive practitioner.
But the usual drains on the practicing physician’s
time and the immense amount of literature (the
reading of which seems to be almost demanded
of the progressive physician) indicate the neces-
sity of short cuts in medical literature.

A resume of each scientific article printed
in this issue will be found under a department
entitled “Readers’ Service.” Here you can
quickly review (average reading time five or
six minutes) the essential parts of each article,
as abstracted by its author, and then you may
determine which papers are of primary im-
portance for your reading.

It is hoped that your interest will be aroused
by the abstracts sufficiently so that you will read
all of them, that at least you will have some
knowledge of the material presented in the body
of the essay.

Hence we suggest that unless you intend to
read The Journal from cover to cover you
turn first to this department and sample the
scientific cuisine herein presented (See page
856).

= f\/|SMS

POSTGRADUATE COURSES FOR
THE UPPER PENINSULA

■ At the September meeting in Grand Rapids,
The Council voted to underwrite the establish-
ment of five Postgraduate Medical Conferences
in the Upper Peninsula similar to those now ex-
istent in the Lower Peninsula. This extension
of service to the Upper Peninsula necessarily en-
tails the expenditure of considerable funds but
it has been felt that these courses should be pre-
sented in some of the smaller population centers.
They probably will not be started until next
spring but it is hoped that the cooperation and
attendance will be sufficient to warrant the con-
tinuance of this expenditure. Special efforts will
be made by the Postgraduate Medical Education
Committee to furnish the best teachers available
on the most practical subjects.

November, 1941

893

PROCEEDINGS OF THE HOUSE OF DELEGATES— 1941

TABLE OF CONTENTS

Introduction Reference

of Committee

Business Reports

Record of Attendance 896

Miscellaneous Addresses :

1. H. Allen Moyer, M.D 897

2. John M. Pratt 897

3. Lt. Col. H. A. Furlong, M.D 899

I. President’s Address 898 909

II. President-Elect’s Address 899 909

III. Annual Report of The Council 900 909

IV. Report of Delegates to the A.M.A 901 909

V. Resolutions :

1. Re : Appreciation to Michigan Legislature and the Gov-
ernor 901 914

2. Re: Special Memberships (Emeritus and Retired)

901, 902, 905, 909 913

3. Re ; Michigan Medical Service :

(a) Callery Resolution 902 909

(b) Brasie Resolution No. 1 902 909

(c) Brasie Resolution No. 2 903 910

(d) Brasie Resolution No. 3 903 910

(e) Brasie Resolution No. 4 903 910

(f) Insley Resolution 905 910

(g) Ekelund Resolution 906 911

4. Re : Election of Delegates to A.M.A 904 914

5. Re: Professional Liaison Committee 904 914

6. Re: Section on General Practice 905 914

7. Re: National Physicians’ Committee 905 914

8. Re: Premarital Instruction 905 911

9. Re: Training of Medical Technicians 906 909

VI. Amendments to Constitution and By-Laws :

1. By-Laws, Chapter 1, new Section 7 re Transfer of

Membership to Another State Society 902 915

2. Constitution, Article III, Section 4, re Honorary Members 903 To 1942 Session

3. C ofistitution, Article IV, Section 3, re Officers and House

of Delegates 903 To 1942 Session

4. Constitution, Article IV, Section 5, re Election by House

of Delegates 903 To 1942 Session

5. Constitution, Article X, Section 1, re clarification of

“session” and “meeting” 903 To 1942 Session

6. By-Laws, Chapter 3, Section 1, re clarification of “ses-
sion” and “meeting” 903 915

7. By-Laws, Chapter 3, Section 7-L, changing word “ses-
sion” to “meeting” 903 915

8. By-Laws, Chapter 3, Section 2, re qualifications of House

of Delegates’ members 903 913

9. Constitution, Article HI, Sections 3 and 5, re Associate

and Junior Memberships 904 To 1942 Session

10. By-Laws, Chapter 5, Section 1, re Annual Meeting of

The Council 904 913

11. C 0‘)%s,titution, Article V, Section 1, re Officers and The

Council 904 To 1942 Session

12. By-Laws, Chapter 5, Section 1, re Executive Committee

of The Council 904 913

13. By-Laws, Chapter 3, Section 7-d, re Election of Dele-
gates and Alternate Delegates to A.M.A 904 913

14. By-Laws, Chapter 4, Section 4, re duties of Secretary. . . . 909 915

15. By-Laws, Chapter 10, Section 1, re change word “session”

to “meeting”; also “present” to “seated” 909 915

16. Unfinished Business from 1940 House of Delegates (Pro-
posed Amendments to Constitution and By-Laws) See

IX-6a 909 912

17. By-Laws, Chapter 7, Section 1, re special membership

applications 914 915

To 1942 Session

Jour. M.S.M.S.

894

PROCEEDINGS HOUSE OF DELEGATES— 1941

VII. Reports of Standing Committees :

1. Legislative Committee 906

2. Distribution of Medical Care Committee 906

3. Medical-Legal Committee 906

4. Representatives to Joint Committee on Health Education 906

5. Preventive Medicine Committee 906

6. Cancer Committee 907

7. Maternal Health Committee 907

8. Syphilis Control Committee 907

9. Tuberculosis Control Committee 907

10. Industrial Health Committee 907

11. Mental Hygiene Committee 907

12. Child Welfare Committee 907

13. Iodized Salt Committee 907

14. Heart and Degenerative Diseases Committee 908

15. Postgraduate Medical Education Committee 908

16. Ethics Committee 908

17. Public Relations Committee 908

VIII. Reports of Special Committees :

1. Committee on Nurses Training Schools 908

2. Medical Preparedness Committee 908

3. Prelicensure Medical Education Committee 908

4. Radio Committee 908

5. Advisory Committee to Woman’s Auxiliary 908

6. Committee on Scientific Work 909

IX. Reports of Reference Committees :

1. On Officers Reports

2. On Council Reports

3. On Reports of Standing Committees

4. On Resolutions

5. On Reports of Special Committees

6. On Amendments to Constitution and By-Laws :

(a) Unfinished Business from 1940 House of Delegates..

Constitution, Article IV', Section 3 (Rejected)

Constitution, Article IX, Section 4 (Rejected)

Constitution, Article XII, Section 1 (Adopted)

Constitution, New Article XII ; Renumbering Old

Article XII to Article XHI (Adopted)

By-Laws, Chapter 10, Section 1 (Adopted)

(b) Re By-Laws changes proposed by 1941 House of

Delegates (Adopted) '.

By-Laws, Chapter 1, New Section 7 (Adopted)

By-Laws, Chapter 3, Section 1 (Adopted)

By-Laws, Chapter 3, Section 7-d (Adopted)

By-Laws, Chapter 3, Section 7-L (Adopted)

By- Law's, Chapter 3, Section 2 (Adopted)

By-Laws, Chapter 5, Section 1 (Adopted)

By-Law's, Chapter 5, Section 1 (Adopted)

By-Laws, Chapter 4, Section 4 (Adopted)

By-Laws, Chapter 10, Section 1 (Adopted)

By-Laws, Chapter 7, Section 1

X. Elections :

1. Councilor of First District 915

2. Councilor of Fourth District 915

3. Councilor of Fifth District 916

4. Councilor of Sixth District 916

5. Delegates to A.M.A 916

6. Alternate Delegates to A.M.A 916

7. President-Elect 917

8. Councilor of Fourteenth District 917

9. Speaker of House of Delegates 917

10. Vice Speaker of House of Delegates 918

XL New Business :

1. Honorarium to Retiring Speaker 918

2. Place and Date of 1942 Annual Meeting 918

911

911

911

911

911

911

911

911

911

911

911

911

911

911

911

911

911

911

912

911

912
912
912

909

909

911
913, 914
911, 912

912
912
912

912

913
913

913

915

915

913

915

913

913

913

915

915

915

1942 Session

XII. Adjournment
November, 1941

918

895

MICHIGAN STATE MEDICAL SOCIETY

Seventy-sixth Annual Session

Proceedings of House of Delegates
Pantlind Hotel, Grand Rapids, Michigan
September 16, 1941

Tuesday Morning Meeting

September 16, 1941

The first meeting o£ the House of Delegates, held in
connection with the Seventy-sixth Annual Convention
of the Michigan State Medical Society, at the Pantlind
Hotel, Grand Rapids, Michigan, September 16, 1941,
convened at nine-fifty o’clock, O. D. Stryker, M.D.,
Fremont, Speaker, presiding.

The Speaker: The meeting will please come to

order.

Dr. Day, are you ready to report for the Credentials
Committee?

Luther W. Day, M.D. : Mr. Speaker, total number
of ninety-nine delegates registered and seated in the
House. That constitutes a quorum of the House of
Delegates. Of this total, there is not a majority from
any one county. Consequently, the House of Delegates
is legally constituted.

RECORD OF ATTENDANCE

COUNTY DELEGATE

1. Allegan

2. Alpena-Alcona-
Presque Isle

3. Barry

4. Bay-Arenac-Iosco

5. Berrien

6. Branch

7. Calhoun

8. Cass

9. Chippewa-Mackinac

10. Clinton

11. Delta-Schoolcraft

12. Dickinson-Iron

13. Eaton

14. Genesee

15. Gogebic

16. Grand Traverse-
Leelanau-Benzie

17. Gratiot-Isabella-
Clare

18. Hillsdale

19. Houghton-Baraga-
Keweenaw

20. Huron

21. Ingham

22. lonia-Montcalm

23. Jackson

24. Kalamazoo

25. Kent

26. Lapeer

27. Lenawee

28. Livingston

C. A. Dickinson
W. E. Nesbitt

Gordon F. Fisher

C. L. Hess
Fred Drummond
Don W. Thorup

R. L. Wade

A. T. Hafford
George W. Slagle

S. L. Loupee

L. M. McBryde

G. H. Frace
J. J. Walch

W. H. Alexander
Don V. Hargrave
George J. Curry
Donald R. Brasie
Frank E. Reeder
Henry Cook
Not represented
Robert T. Lossman

M. G. Becker

Luther W. Day

C. A. Cooper

C. W. Oakes

C. F. DeVries

T. I. Bauer

L. G. Christian
W. L. Bird

J. J. O’Meara

H. A. Brown

I. W. Brown
Louis W. Gerstner

A. V. Wenger
Carl F. Snapp
George H. Southwick
A. B. Smith

W. C. Beets
P. W. Kniskern

D. J. O’Brien

M. R. McGarvey

D. C. Stephens

Session
1st 2nd 3rd

X X —

XXX

X X

XXX

XXX

XXX

XXX

XXX

XXX

XXX

XXX

XXX

XXX

XXX

XXX

X X

XXX
XXX
X

XXX

XXX

XXX

XXX

XXX

XXX

XXX

XXX

XXX

XXX

X X

XXX
XXX
XXX
XXX
XXX
— XX

X

XXX

X X

XXX
X X

29. Luce

30. Macomb

31. Manistee

32. Marquette-Alger

33. Mason

34. Mecosta-Osceola-
Lake

35. Medical Society of
North Central
Counties

36. Menominee

37. Midland

38. Monroe

39. Muskegon

40. Newaygo

41. Northern Michigan

42. Oakland

43. Oceana

44. Ontonagon

45. Ottawa

46. St. Clair

47. St. Joseph

48. Saginaw

49. Sanilac

50. Shiawasse

51. Tuscola

52. Van Buren

53. Washtenaw

54. Wayne

55. Wexford

Henry E. Perry

D. Bruce Wiley

E. A. Oakes

V. Vandeventer

W. S. Martin
Gordon Yeo

C. R. Keyport

H. T. Sethney

H. H. Gay

D. C. Denman

E. O. Foss

E. N. D’Alcorn

O. D. Stryker
Fred C. Mayne
C. T. Ekelund

Z. R. AschenBrenner

B. T. Larson
Merle G. \Vood
W. F. Strong
A. E. Stickley
A. L. Callery
R. A. Springer

C. E. Toshach

F. O. Novy
R. K. Hart

I. W. Greene
T. E. Hoffman
W. R. Young

John A. Wessinger
Dean W. Myers
L- J. Johnson
L. E. Knoll
R. H. Pino
Gaylord S. Bates
Henry A. Luce
R. L. Novy
Douglas Donald

A. E. Catherwood
T. K. Gruber

W. D. Barrett
R. M. McKean
Allan McDonald
H. J. Kullman
L. J. Hirschman

E. D. Spalding

G. C. Penberthy
W. B. Cooksey
C. E. Dutchess

E. A. Osius

J. H. Andries

R. C. Jamieson

H. F. Dibble

S. W. Insley

P. L. Ledwidge
C. F. Brunk
Wm. S. Reveno
C. F. Vale

F. W. Hartman
R. V. Walker
C. E. Simpson

J. A. Kasper
L. J. Morand
C. K. Hasley

B. L. Connelly

C. E. Lemmon
E. R. Witwer

L. O. Geib

M. H. Hoffmann
Arch Walls

C. S. Ratigan
W. Joe Smith

XXX

XXX

XXX

XXX

— X

XXX

XXX

XXX

XXX

XXX

XXX

XXX

XXX

XXX

XXX

XXX

X

X

XXX

XXX

XXX

XXX

XXX

X X

XXX
XXX
X X X
XXX
XXX
XXX
XXX
XXX
XXX
XXX
X

X X X

XXX
XXX
XXX
XXX
XXX
XXX

XX

X X X

XXX
XXX
X X X

XXX
XXX

X X

XXX

XXX

XXX

XXX

XXX

XXX

XXX

XXX

XXX

XXX

XXX

X X

XXX

XXX

XXX

XXX

XXX

X X

XXX
XXX
X X

The Speaker: According to the report of the Cre-
dentials Committee, the House of Delegates is now
legally constituted. The report of the Credentials Com-

Tour. M.S.M.S.

896

PROCEEDINGS HOUSE OF DELEGATES— 1941

mittee will be taken as the roll call, if there is no objec-
tion from the House.

You will find in the Handbook the appointment of
the various reference committees.

The Speaker will dispense with the Speaker’s address
due to the amount of work which we have before us.

For many of you, this is your first meeting. Many
of the men who were with us in former years are now
in army service. For you who are new, and for all
of you, remember that you constitute the legislative
group of this Society. Upon what you think, upon
what you say and what you do here will depend the
future of the Michigan State Medical Society.

At this time the State Health Commissioner has a
few words he wishes to say.

H. Allen Moyer, M.D. : Mr. Chairman and Dele-
gates: I bring greetings from the Health Department
to the Michigan State Medical Society.

There is one subject that I wish to bring before
you today on which you may take action some time
in the future. As you all realize, today in the State
of Michigan cancer is the second greatest cause of
death, and we have no way of knowing the number
of deaths except through the death notices that are
presented to be recorded.

I would like to have this body take into consideration
the subject whether cancer should be registered as a
contagious disease. It is not a contagious disease but
it should be recorded, that we may Imow the number
of cases and follow through to find out how many cures
are being effected in the State of Michigan. If can-
cer is recorded, the same as a contagious disease, there
would be the understanding that the doctor in attend-
ance on these cases would be contacted at least once or
twice a year, to follow through and to find out how
long these patients are living after being treated. We
could reduce the number of deaths, and know the num-
ber of cures being accomplished. It would be of great
benefit, and it would be a record which would be very
beneficial to the State of Michigan.

New York State and Massachusetts have adopted
this form. I wish the delegates would consider this
and that some action be taken in the future that would
justify the Department of Public Health in reporting
cancer. I hope you take this question under considera-
tion because I feel it is vital to the records in the
State of Michigan.

The Speaker: I wish to make one change which
has just been invited to my attention, in the member-
ship of the Reference Committee on Reports of Stand-
ing Committees. Dr. G. W. Slagle will replace Dr.
Harvey Hansen, Calhoun County.

At this time we will hear from John M. Pratt of
the National Physicians Committee. Dr. Luce !

Henry A. Luce, M.D. (Wayne) : Gentlemen, not
sailing under false colors, for once in my life, I am
being honored this morning by being asked by Dr. J.
Milton Robb to take his place.

At this time, Mr. Chairman, I wish, if it would be
in order, that this House of Delegates instruct our
Secretary to send to Dr. Robb a telegram of regrets
that he is sick and unable to attend.

The Speaker: That is in order and will be done.

Henry A. Luce, M.D. : Several years ago, a group
of physicians, representative doctors, doctors standing
high in their profession, doctors whose integrity was
unquestioned, organized the National Physicians Com-
mittee for the Extension of Medical Service and secured
the services of John M. Pratt as Executive Adminis-
trator.

November, 1941

C)n behalf of Dr. Robb, on behalf of those who
believe in individualism in this country, it is a pleas-
ure to introduce to you John AI. Pratt.

John AI. Pratt: Dr. Stryker, Dr. Luce and mem-
bers of the House of Delegates of the Michigan State
Medical Society: Personally, I always feel very much
at home with the doctors of the State of Alichigan.

I am much pleased that it falls to my lot to be
with you here today, and I am to have the privilege
of talking at the County Secretaries Conference to-
morrow. In this case we are reversing the process. In
nearly all instances I have been able generally to out-
line the why, the wherefore, the method, and the prog-
ress at a general meeting, before talking to a House
of Delegates. The members of the board of the Na-
tional Physicians Committee are hoping that before your
House of Delegates adjourns you will have sufficient
insight, sufficient knowledge and sufficient interest in
this vital aspect of medicine to take some formal action.

On a question as vital and as important as this one,
it is a very simple think to take an hour, or more,
in discussing the details of the problem. I shall attempt
only to place before you what we conceive to be the
basic issues involved, that were responsible for bring-
ing into being the National Physicians Committee.

In 1933 there were brought into the picture in this
country two wholly new factors or concepts : first,
making a business out of politics.

Second, the establishment of controls through the
agency of propaganda. That was new to us. I only
need to use medicine to illustrate what it meant. You
men are all familiar with the fact that in July of
1938 the government called into being the National
Health Conference. That was only one of many, but
it established a kind of precedent, because that Na-
tional Health Conference was never designed or intended
to do anything about this health problem save to pro-
vide the sounding board and the base of propaganda
that emanated from it.

In the following October the American Medical Asso-
ciation was hailed before the federal grand jury, and
again we had the excuse or the base for a nation-wide
effort to tell all of the people in this country that the
physicians of the United States had not been doing
their job in providing medical service.

In December of that year. Dr. Fishbein, Dr. West,
Dr. Leland, two other men from Chicago, the American
Medical Association, the Washington District Associa-
tion, the Houston-Texas Association, and some four-
teen other physicians were placed under criminal indict-
ment.

That Health Conference, that grand jury action, the
indictment of these medical men were important for
one thing. They provided the base of a nation-wide
publicity which was used for one purpose, and that pur-
pose was to break down the confidence of the American
people in our system of distributing medical service
and, to an extent, discredit the practicing physician, to
the end that we might bring into being in this country
a revolutionary plan of providing medical service.

Those grand jury indictments in December of 1938
were followed in February by the introduction of the
Wagner National Health Bill. This was to implement
the idea behind all of these moves. This was new,
not only new to medical men but new in all of the
things undertaken in this nation.

As a consequence, after the indictment of these men
before the federal grand jury, American medicine,
organized for nearly one hundred years, performing
the greatest service of any professional or trade group
in this country, frankly did not know what to do.

Medicine was not geared up to meet that kind of
attack ; no group in this country was geared up to
meet it. It is by accident that the whole of this effort

897

PROCEEDINGS HOUSE OF DELEGATES— 1941

had its beginning’s in this state at a meeting of your
State Council in Detroit, November, 1938.

From that emanated the most intensive, the most
effective, the most comprehensive counter-propaganda
effort that had ever been made in the United States.

Most of you men probably do not realize all that
has been done, but, following this meeting in Detroit,
interested physicians went to Chicago, Minneapolis and
St. Paul, out to San Francisco and back to Kansas City
and St. Louis and Indianapolis.

In November, 1939, the National Physicians Com-
mittee for the Extension of Medical Service was or-
ganized. There were two essentials. First, to tell the
people that all of the things they were being told about
the inadequacy of medical service were only partially
true, and that there were other truths of more impor-
tance to the public than the part truths they were
being told.

Second, the necessity for organized medicine assum-
ing the responsibility for providing, to the very ulti-
mate, medical service for all the people.

There have been possibly as many as two hundred
experimental efforts made to provide medical service.
Again Michigan is at the forefront. In May of last
year I had the privilege of thoroughly canvassing the
medical situation in this state, with all of the detailed
information in connection with its medical service. I
have followed closely the development of your Michi-
gan Medical Service.

Two states, Michigan and California, by making these
experimental efforts, in many respects wholly success-
ful, have done more than any other single development
to insure a continuation of the medical profession con-
tinuing to provide medical care without political inter-
ference.

If you will keep in mind two new concepts on
the American scene — government in business, controls
by propaganda — you will understand that the National
Physicians Committee for the Extension of Medical
Service is the only agent of the medical profession to
undertake the counter effort that is essential, to pre-
serve the independence of medicine in the United States.

The Speaker: Thank you, Mr. Pratt.

We will proceed to the next order of business, which
will be the President’s address, P. R. Urmston, M.D.

L President's Address

Mr. Speaker and Members of the House of Dele-
gates and Officers :

After fifteen years as an officer of the Michigan
State Medical Society, serving during these years as
Chairman of The Council and Executive Committee
and the last two years as an ex officio member, I should
be able to write a volume in the interest of our organi-
zation.

I have watched the growth of the Michigan State
Medical Society in the last few years from a mod-
erately active organization to one capable of handling
the interests of any large corporation. This change has
been brought about since the centralization of our activi-
ties in our executive offices in Lansing and the co-
operation of the Secretary and Executive Secretary.
Much of the credit is due to our Executive Secretary,
Mr. Burns.

“Choose Your Councilor Wisely"

A councilor should be chosen by his district for
his executive ability, stamina, endurance, longevity and
his willingness to give us time from his practice to ful-
fill his obligations. Therefore, a councilor should be
chosen wisely. The members of the Executive Com-
mittee of The Council are the Chairman, Vice Chairman
and Chairman of the Finance, County Societies and
Publication Committees. They are elected by The Coun-

898

cil. The Speaker of the House is a member of the *
committee by authority of the House of Delegates,
with the right to vote. Most of the administrative |
activity of the Society is done by the Executive Com- !
mittee. This has been one of our most active years
and I wish to praise The Council and its Executive '
Committee for their good judgment and hard work.

Proposed Amendments to Constitution

The value of the experience of our Past President
to the House of Delegates has been a matter of dis-
cussion for several years. An amendment to the Con-
stitution was presented to the 1940 House of Delegates
proposing that officers, past presidents and councilors
be made ex officio members of the House of Dele-
gates. The officers and councilors should accept this
recognition as their presence is valuable. This all
leads up to the essential point, the status of the active
President, President-Elect and the Secretary as mem-
bers of the Council and Executive Committee. Why
not give more voice and power to these officers during
their incumbency? Responsibility is theirs now, with-
out the right to vote.

Medical Preparedness

“One examination for selectees” was the subject of
an article on the President’s Page in the April M.S.M.S.
Journal. The principle set forth in this article is about
to be put in effect in the Upper Peninsula, that is, a
traveling army induction unit. We hope this will soon
be universal. The army rejections will then be higher
by the economic loss and disappointments of the
selectee will be lower.

The rules and regulations for physical requirements
for 1-A and 1-B selectees have changed so fast that
it seems unwise to quote them at this time. Under new
regulations many remedial cases will then be cared
for by the army.

Rehabilitation of the rejected draftees has been
studied by your president and I refer you to the Presi-
dent’s Page of the Febnrary M.S.M.S. Journal. At the
present time no plan for the rehabilitation of rejected
draftees is feasible but when it does become so, either
by the Federal government, state or local agencies, we
will always insist (here I refer you to the second rec-
ommendation of The Council, on page 39 of your
Handbook) that the physician-patient relationship and
free choice of Doctor of Medicine shall be maintained.

At the present time the public is not demanding any
such action as shortages in essential comforts have
diverted their attention.

Thanks to Committees

All committees appointed by your president have
fulfilled my expectations and I wish to commend their
work. Read their reports in the Handbook and Journal.

The death of Dr. C. K. Valade, chairman of the
Syphilis Control Committee, was a shock and a loss
to the Michigan State Medical Society. No resigna-
tions or changes in The Council or any Committees
this year speaks well for the future welfare of our
organization.

Important Role of the General Practitioner in Medicine

A newspaper article under the heading “Army Spe-
cialists vs. the General Practitioner” would lead the pub-
lic to believe that the M.D.s doing general practice
are not keeping up to date due to lack of postgraduate
educational facilities. Our extramural postgraduate
meetings, the universities’ postgraduate courses, and
this week’s M.S.M.S. convention (with thirty out-of-state
guest essayists whose presentations are especially written
for the general practitioner) should put him on a basis
in the important field of general practice comparable
to the standing of a specialist in his field.

Jour. M.S.M.S.

PROCEEDINGS HOUSE OF DELEGATES— 1941

Without the general practitioner Medicine, as prac-
ticed today, could not exist. The A.M.xA.. is recognizing
him in a separate section in medicine. May the time
never come when we all become narrow-minded bj' a
restricted specialty viewpoint.

MSMS Endowment for Postgraduate Medicine

With increasing taxes, inheritance taxes on estates
and many others we must look to the future in financ-
ing our postgraduate courses. At the present time only
a small part of the cost is carried by the MSMS.
Several years ago The Council proposed that a fund
be created for this purpose so that the MSMS could
finance all extramural postgraduate courses and other
postgraduate activities except those provided exclusively
by the two universities. I recommend that the House
of Delegates and The Council propose changes in our
Constitution and By-Laws for the creation and custody
of such a fund for the endowment of postgraduate edu-
cation for the general practitioner as an activity of
the MSMS. I recommend that the House of Delegates
instruct The Council to set aside an amount equal to
ten thousand dollars to start this fund and additional
sums each year until such time as the fund is suf-
ficient to endow postgraduate education. This fund
could receive other monies and bequests from our mem-
bership and lay benefactors. Several have already ex-
pressed their wish to donate to such a fund if once
initiated by the Society.

Finis

Mr. Speaker and House of Delegates, I appreciate
the honor of being President and I hope I have lived up
to your expectations. After fifteen years of service, I
do not expect to drop my interest in the welfare of
my profession. I shall still be ver}' active in organized
medicine.

The Speaker; The address of the president will be
referred to the Reference Committee on Officers’ Re-
ports.

I understand that Colonel Furlong is with us, and it
is my pleasure to call on him at this time.

Lt. Colonel Harold A. Furlong, Al.D. : Air. Speaker,
Alembers of the House of Delegates : Last year, when
I was called into military servdce, my first duty was to
meet with your Medical Preparedness Committee and
the members of the Executive Committee. That was
a very pleasant occasion. I am sure that, had I kno^^■n
then what I know now about the Selective Service, I
wouldn’t have looked forward so eagerly to this year.

It is a very unusual honor that you have bestowed
upon me this morning to attend a meeting of the
House of Delegates. I frankly asked for that per-
mission in order that I might express officially to the
medical profession of Alichigan the thanks of the Gov-
ernor and the Selective Service System of Alichigan
for the very vital part that the doctors of medicine
have played in this program. It has been pleasant to
cooperate most closely with all the facilities that or-
ganized medicine in Alichigan had to offer. We have
received most excellent help from the executive office,
under Air. Burns. The AI.S.AI.S. Journal has been
very helpful ; the Executive Committee and The Coun-
cil have been very helpful. The tremendous load that
the doctors of Alichigan have borne in the past year,
in carrying out this program, surpasses all imagination.
Over 130,000 examinations have been performed. About
50,000 men have been taken into the Selective Service
in Alichigan. Not only the immediate facilities of the
State Aledical Society but the Department of Health
and other agencies, such as the Alichigan Hospital As-
sociation and the Board of Registration in Aledicine
have been most helpful.

November, 1^1

The name of ever^* doctor who has been appointed
in Alichigan to service on Selective Service has been
cleared through the Board of Registration in Medicine.
I think you can see what that has meant. There have
been 1,451 doctors of medicine serving as examiners
for local boards. Three hundred eighty-six men have
served on the medical advisory boards, and there are
nineteen doctors, one on each of the nineteen appeal
boards, a total of 1,856.

There have been, I am sure, many occasions when
the doctors of Alichigan were somewhat annoyed by
the hea\^ load that has been placed upon them at
various times. It was not possible for us to give you
all that you wanted in the way of supplies.

M'e are very carefully recording the results of your
work, and we anticipate that, when this program is
through in Alichigan, we will have enough records, care-
fully kept and tabulated, that a very comprehensive
study may be made of the physical condition of reg-
istrants.

In fact, people who come here from national head-
quarters and look over what we are doing in the way
of tabulating this information for the State of Michi-
gan indicate verj' clearly that we are doing a better
job than even the national government itself is under-
taking.

Tomorrow the official representative of the national
headquarters of Selective Service is coming here pri-
marily to express appreciation for your assistance.

Another job has been assigned to me, that of Ad-
ministrator to the State Council of Defense. I can
assure you that, in addition to the heavy load which
you have been called upon to give for Selective Serv-
ice, you will be invited to give advice and help in or-
ganizing all the medical resources of the State of
Alichigan that will be necessary’- under the civilian de-
fense program.

Again I want to express to you my appreciation for
the privilege of appearing before you this morning,
and mj^ very profound admiration for the work that the
Alichigan doctors of medicine have done in national de-
fense.

The Speaker: Thank you. Colonel Furlong.

Our next order of business is the President-elect’s
address, Henry R. Carstens, AI.D.

II. President-Elect's Address

With this, the Seventy-Sixth Annual Meeting, the
Alichigan State Aledical Society completes three-quar-
ters of a century of able service to the citizens of this
state and to the medical profession which serves them.
The record is long and honorable, and of it we may
justly be proud. The speaker, naturally, has a deep
feeling of gratitude ior the honor which his fellow
practitioners will bestow* upon him this week.

The activities of the Alichigan State Aledical Society
in the scientific phase of the practice of medicine are
well known and need not be repeated here. The splen-
did program which will be presented at this meeting is
but one manifestation of the educational program of
the State Society, both for its members and for the
public. The complete list of activities of the Society
cannot be covered on this occasion, but in brief, one
or two items merit special mention.

The first is concerned with the project, which was
the result of manj* 3*ears’ study of some of the inequali-
ties in the distribution of medical care. For over ten
j^ears, the Society has made a thorough study of this
problem ; this study culminated in the sponsorship of
Alichigan Aledical Service, the nonprofit corporation
which makes provision for the budgeting of the costs
of medical care by means of small monthly pajTnents.
The plan has now been in active operation for eighteen

899

PROCEEDINGS HOUSE OF DELEGATES— 1941

months, and gives every evidence of serving the three-
fold purposes for which it was founded. These were
(1) to make available to the citizen of the moderate
income group, medical services of which he might
be in need, without disruption of his budget through
unforeseen incurrment of substantial and unexpected
financial obligations. At the same time (2) the physi-
cian is assured of fair compensation for his services.
And, finally (3) such a plan of voluntary protection
(based upon insurance principles) by the individual
himself, will help to forestall the proposals of those
who feel that some compulsory health insurance plan
is the only solution.

In accordance with the instructions of the House of
Delegates, operations were started on March 1, 1940.
Although plans were carefully made in advance, it was
inevitable that there would be numerous unforeseen
problems arising after the plan was actually in opera-
tion. Some of the difficulties seemed insurmountable, but
due to the earnest and conscientious work of the Board
of Directors and its Executive Committee, Michigan
Medical Service has solved the great majority of prob-
lems as they arose and the plan has grown rapidly in
the last eighteen months. Many problems still remain
for solution in the present and in the near future. One
of these problems is the rapid growth mentioned, the
number of subscribers having increased in the short
space of time up to approximately 193,000 individuals
as of this date. All indications point to the fact that
the program is soundly planned and appears to be an
answer, in large part, to some of the problems of
the distribution of medical care. As further evidence,
it is noted that in all parts of the nation, the medical
profession is watching the progress of the Michigan
plan and has started similar plans with a view to solv-
ing the problems in their own communities. Well over
half of the states now have started plans or have com-
pleted the ground work which will permit them to
start their plans within a short time. The whole pro-
gram comprises a great social experiment with every
indication pointing to its success in solving some of
the major medical economic problems of our citizens.

The full details will be presented tomorrow after-
noon in the reports at the meeting of the membership
of Michigan Medical Service, the membership including
the delegates of this House.

Another major matter which will be of increasing
importance and which will require more and more
study by the Michigan State Medical Society during the
next year or two is the matter of the national defense.
With the kaleidoscopic changes in the picture of world
affairs, it is not remotely possible to forecast what the
future will bring. In the meantime, it may be stated
that the medical profession of this state has already
performed notably in the nation’s program for national
defense.

Almost 2,000 physicians have served, without re-
muneration, on the Selective Service local examining
boards and district advisory boards ; they have put in
long hours of conscientious work in this service. In
addition, many of our physicians, particularly the
younger ones, are already on active service. Some are
serving in the navy and with the marines, many are
on duty with the national guard. Tlie profession may
well be proud of the large number of its members who
hold appointments in Reserve Corps of the army.
Michigan has always been among the leaders in this
respect. There are at present over 400 physicians in
this state who hold appointment as medical reserve
officers. Of these, approximately 250 are on active
duty. Of the balance, the great majority are completing
internships, are senior officers, or are assigned to
War Department units, so that actually there are
hardly a score at the present moment available for
assignment in the Michigan Military Area.

900

This is a record in which the medical profession I
may take pride. And still, due consideration must be I
given to needs which the future may bring in the event I
of an even greater national emergency. With every i
confidence, one may state that the medical profession i
of Michigan will rise to the emergency as they have
during previous wars that have occurred since the
founding of our Society.

There are many other activities which will occupy
the Society during the coming year. Particular atten-
tion may be drawn to the reports of the many com- ,
mittees. Their industrious members have accomplished
much during the past year, and most of the commit- '
tees have long range programs which will occupy our
attention for the coming year and even further in ]
the future. 1

During its long and honorable historj^, the Michigan |
State Medical Society has been confronted with in- j
numerable problems, and these have been studied and j
solutions found to the best interest of the citizens of J
this state and the practice of medicine. In the future, <
there will be even more problems. I know that every ^
one of us has every confidence that the correct solu- j
tion will be found in the earnest deliberations of the ;
Society’s governing body, the House of Delegates, and J
the able activities of its executive body. The Council,
and the Officers. May our State Society prosper and
long continue into the future its enviable and honor- >
able record.

The Spe.aker: The address of President-elect Car- ;
stens will be referred to the Reference Committee on
Officers’ Reports.

The next order of business is the annual report of
The Council, A. S. Brunk, M.D.

III. Annual Report of the Council

Mr. Speaker and ^Members of the House of Dele-
gates :

The Annual Report of The Council for the year
1940-41 appears in the Delegates’ Handbook beginning
at page 29. As this report was written in July in order
that it might appear in print, we wish to submit addi-
tional information on matters which have been con-
sidered by The Council and its Executive Committee
during the past two months.

1. Membership. — The membership of the Michigan
State Medical Society, as of September 12, 1941, totals
4,432, including 82 military members who were granted
a remission of dues.

2. Michigan Medical Service. — The enrollment in
Michigan Medical Service has increased to 193,186 as
of August 31, 1941. In addition to this widespread
acceptance of the program by the public, it is refresh-
ing to observe that the number of participating doc-
tors has increased each month, until at present 3,559 are
registered, which is approximately 90 per cent of the
total number of licensed practicing physicians in Michi-
gan.

The benefits of the program are well established,
both for the patients and the doctors. The great flexi-
bility of services means more adequate care for the
patients and greater remuneration for the doctors.

Services have been provided for more than 29,000
patients, and payments in excess of $650,000 have been
paid to doctors for these services. Complete data as
to the expansion of Michigan Medical Service will
be presented at the meeting of the members.

3. Medical Relief. — The administration of medical
relief to those on Welfare is still in a chaotic condi-
tion, being complicated by the ruling of the Michigan
Crippled Children Commission re fee schedule.

Jour. M.S.M.S.

PROCEEDINGS HOUSE OF DELEGATES— 1941

From the Secretary’s Report presented to the Dele-
gates last evening (September 15), it would appear that
at least one-third of our county medical societies have
lower fee schedules for medical care of indigents (in-
cluding afflicted adults) than the present fee schedule
of the Crippled Children Commission, which at best
represents only the cost price of rendering these serv-
ices to wards of Government. Therefore, the physicians
in some twenty-two Michigan counties are working
under fee schedules that represent a return of less than
the cost of performing the services ! ! !

Much work by our county medical societies re med-
ical relief is indicated. In fact, it is felt that this is
the major problem facing the Michigan medical pro-
fession today. If it is not solved, quickly and satis-
factorily, it will be reflected in our private practices.

Michigan’s Welfare Law of 1939 set up the cardinal
principle of the physician-patient relationship (free
choice of physician by welfare patients). This law is
not being complied with in some counties. A recom-
mendation on this matter follows.

4. Authorisation to Levy Assessments^ — In 1938, 1939
and again in 1940, the House of Delegates authorized
The Council to levy an assessment of $5.00 on every
member of the M.S.M.S., as seemed justified in the
opinion of The Council. The Council is gratified at
your confidence and is happy to state that matters were
so well arranged by its Finance Committee that no
direct assessments were required during the last three
years. A recommendation on this subject follows.

5. The Intangibles Tax Law of 1939, has, since its
enactment, been a source of confusion and annoyance
to thousands of Michigan citizens who have attempted
to comply with its complicated provisions. This of
course includes members of the medical profession.
Most of us were sorry that the attempt to repeal the
law made in the 1941 Legislature by Senator Earl W.
Munshaw, did not meet with success ; such action would
have resulted in the enactment of a better and less
complicated statute.

Some Michigan lawyers have advised individual phy-
sicians that they were not responsible for the payment
of intangible taxes on accounts receivable as these
represented persoml services. This question came up
on several occasions, with the result that The Council
ordered that a legal opinion be secured. This was ob-
tained, and is on file in the executive office at Lansing.

Recommendations

The Council’s first five recommendations are published
in the Handbook on page 39. I shall read them to re-
invite them to your attention ;

1. That favorable consideration be given to a res-
olution expressing appreciation and gratitude to mem-
bers of the Michigan Legislature and to the Governor
for their courteous reception extended representatives
of the medical profession, and the thoughtful consid-
eration they gave to medical and health measures com-
ing before them.

2. That the State Society develop, or join in the de-
velopment of, some plan of rehabilitation of rejected
draftees, in which the physician-patient relationship and
free choice of doctor is maintained.

3. That county societies having arrangements where-
by medical welfare (including afflicted adult) care is
given at less than cost price, be urged immediately to
study and revise their schedules of benefits so that in-
dividual members are not penalized by being forced to
perform services at a financial loss.

4. That approval be given by the House of Delegates
of the resolutions of the state’s fifty-five county medical
societies recommending renewal of the Charter of the
Michigan State Medical Society.

November, 1941

5. That the recommendations of the special commit-
tee appointed to study the problem of election of dele-
gates and alternate delegates to the A.M.A. be favor-
ably considered.

^

The Council offers these additional recommendations,
covering matters presented in this Supplementary Re-
port :

6. That aggressive action be taken by county medical
societies, where indicated, to the end that county social
welfare boards comply with the Michigan Welfare Law
of 1939 re free choice of physician by welfare patients.
Further, that county societies contact their Boards of
Supervisors before October 1, on which date their an-
nual budgets will be adopted.

7. That the House of Delegates reaffirm its authori-
zation to The Council to levy a capital assessment, or
assessments, not to exceed a total of $5.00, as seems
justified in their considered opinion.

^

The Speaker: The annual report of The Council

and the supplemental report will be referred to the Ref-
erence Committee on Reports of The Council.

We will now have the report of Delegates to Ameri-
can Medical Association, by Dr. Luce.

IV. Report of Delegates to A.M.A.

Henry A. Luce, M.D. : The report of the Delegates
to the A.M.A. is printed in the Handbook. No addi-
tional reports are necessary, no matters having tran-
spired.

The Speaker: This report will be referred to the

Reference Committee on Officers Reports.

The Speaker will now declare a recess of five min-
utes.

(Recess.)

The Speaker: The House will please be in order.

The next item of business is the offering of resolu-
tions.

V. Resolutions

Dean W. Myers, M.D. (Washtenaw) : Mr. Speak-

er, in accordance with the recommendation of The
Council, presented by Chairman Brunk, I wish to offer
this resolution :

V-1. APPRECIATION TO MICHIGAN LEGIS-
LATURE AND GOVERNOR

Resolved, that the House of Delegates of the Michigan State
Medical Society, in session September 16, 1941, place on its
minutes an expression of appreciation to the members and the
officers of the Michigan Legislature, and to His Excellency, The
Governor, for the courteous reception extended to the repre-
sentatives of the medical profession and for the thoughtful con-
sideration they have given medical and public health measures
that have come before them this year.

O. D. Stryker, M.D.,
Speaker of the House of Delegates.

Attest :

L. Fernald Foster, M.D., Secretary.

The Speaker: That resolution will be referred to

the Reference Committee on Resolutions.

V-2. SPECIAL MEMBERSHIP (EMERITUS,
RETIRED, HONORARY)

Fred Drummond, M.D. (Bay-Arenac-Iosco) :

Whereas, Charles W. Ash, M.D., of Bay City, Michigan,
Member of the Bay County Medical Society, has fulfilled the
requirements for Retired Membership of the Michigan State Med-
ical Society as provided in Article three (3), Section six (6),
of the Constitution,

Be It Resolved, that the House of Delegates transfer Dr. Ash
to the Retired Membership roster.

Whereas, C. M. Swantek, M.D., of Bay City, Michigan, mem-
ber of the Bay County Medical Society, has fulfilled the re-

901

PROCEEDINGS HOUSE OF DELEGATES— 1941

quirements for “Retired Membership” of the Michigan State
Medical Society as provided in Article three (3), Section six
(6), in the Constitution,

Be It Resolved, that the House of Delegates transfer Dr.
Swantek to the Retired Membership roster.

A. E. Stickley, M.D., Ottawa:

“Whereas, A. Leenhouts, M.D., of Holland, Michigan, has
been in the active practice for over 50 years and has been a
member of the County and State Medical Societies for more
than 25 years, be it resolved that the status of A. Leenhouts,
M.D., now be that of Emeritus Member of the Michigan State
Medical Society.”

R. A. Springer, M.D., St. Joseph :

Whereas, J. H. O’Dell, M.D., of Three Rivers, Michigan, has
fulfilled the requirements for Retired Membership,

Be It Resolved, that he be accorded Retired Membership priv-
ileges.

Donald R. Brasie, Genesee :

Whereas, C. H. O’Neil, M.D., of Flint, Michigan, has retired
from the active practice of Medicine and Surgery, having been
an active member of the Genesee County Medical Society for
the past thirty years.

Be It Resolved, that C. H. O’Neil, M.D., be placed on the
Retired Membership list of the Michigan State Medical Society.

M. G. Becker, M.D., Gratiot-Isabella-Clare :

Whereas, Fred J. Graham, M.D., Alma, has been in practice
for fifty years, and

Whereas, he has been a member in good standing of the
Gratiot-Isabella-Clare County Medical Society for twenty-five
years, and

Whereas, he has been unanimously recommended by the
Gratiot-Isabella-Clare County Medical Society, we wish to pre-
sent his name for your favorable consideration, for Emeritus
Membership.

Frank O. Novy, M.D., Saginaw:

Whereas, M. D. Ryan, M.D., Saginaw, has been in practice
for fifty years, and

Whereas, he has met all requirements for Emeritus Member-
ship,

Be It Resolved, that he be granted such membership in the
Michigan State Medical Society.

The Speaker: All resolutions relative to special

memberships will be referred to the Reference Commit-
tee on Resolutions.

VL Amendments to Constitution
and By-laws

VI-l. BY-LAWS, CHAPTER 1, NEW SECTION 7,
RE: TRANSFER OF MEMBERSHIP TO
ANOTHER STATE SOCIETY

E. D. Spalding, M.D. (Wayne) : Amend Chapter

I by adding a section to be known as Section 7.

Sec. 7. Resignation for transfer of membership to another
State Society shall be effected in the following manner:

Any member in good standing, not facing charges of unethical
conduct, whose State and County dues are not in arrears, and
who has moved his home or office to another State, may tender
his resignation, which shall be effective at the beginning of the
next quarter. Such resignation shall be received and accepted
by the State Secretary, who shall give the departing member
certification of good standing.

Provided the portion of the calendar year following such res-
ignation is not less than one-quarter, the secretaries of the State
and County societies shall refund any dues already paid for
the remainder of the year, calculated to the nearest quarter.

The Speaker: That will be referred to tbe Refer-

ence Committee on Amendments to Constitution and
By-Laws.

A. L. Callery, M.D., St. Clair:

V-3(a). RE: MICHIGAN MEDICAL SERVICE

At a regular meeting of tbe St. Clair County Medical
Society, Tuesday evening, September 9, 1941, at Port
Huron, Michigan, after a lengthy discussion of the
Michigan Medical Service, participated in by a majority

902

of members present, a motion was made and carried
by a vote of 25 to 1 (five members not voting), voicing
their disapproval of the manner in which the service
of this organization is functioning. The following res-
olution was prepared and the delegate instructed to
present it at this meeting.

Whereas, Michigan Medical Service has not been function-
ing to the satisfaction of the members of the medical profession,
and

Whereas, Fees have been reduced to a figure which is not
commensurate with the services rendered, and even lower than
agreed upon, and are slow in being paid or not paid at all, and

Whereas, Members participating in this service are being ac-
cepted by Michigan Medical Service in higher income brackets
than originally agreed upon, and

Whereas, In our opinion, instead of helping the physicians
of St. Clair County, our services are being actually cheapened
by the fees paid, and that we are worse off by participating
in this Service than we were before its organization, and for
this reason many of our members have cancelled their enrol-
ment, and

Whereas, In our opinion services being rendered by old line
Insurance companies are far more satisfactory to everyone.

Therefore, Be It Resolved, that our delegate be instructed
to present this Resolution to the House of Delegates and mem-
bers of Michigan Medical Service urging the discontinuance of
Michigan Medical Service in its entirety.

A. L. Gallery, M.D. : I have carried out my in-

structions.

The Speaker: The resolution offered by Dr. Cal-
lery will be referred to the Reference Committee on
Reports of The Council.

Donald R. Brasie, M.D. : Mr. Speaker and Gentle-
men : I have here on the table a lengthy resolution of

the Genesee County Medical Society reiterating again
their objections to Michigan Medical Service. We were
all through it last night. I don’t think it needs repeti-
tion. I might say we think Dr. Luce is a very excellent
red flag waver. He at least has the courage of his
convictions on that. We don’t feel that the dangers are
quite as urgent. We don’t feel that it is necessary in
good times, in a well-paid group, to reduce our usual
fees 25 per cent under the average in our county, which
Michigan Medical Service represents. We do not feel
that this hits the low income group.

Dr. Carstens, last night, made the first admission
that, perhaps, it was the moderate income group. In-
cidentally, one reason we are so concerned, gentlemen,
is because the group that is now insured in the Medical
Service represents 90 per cent of our practice in Gen-
esee County. It does not represent three or four cases,
as some of the men have had, who are so much in
favor of Michigan Medical Service. It represents 90
per cent of our practice, and it represents a fixation of
a top fee.

Henry A. Luce, M.D. : Mr. Speaker, I rise to a

point of order. In introducing a resolution, is it the
ruling of the Chair that a man makes an argument
about his resolution?

The Speaker: No, it is not. You preceded me a

few moments. I think the resolution should be of-
fered and discussion held over until after the report of
the Reference Committee.

Donald R. Brasie, M.D. : I stand corrected. I am

sorry. I was only trying to explain why it was put in.

These are the resolutions we were instructed to pre-
sent.

V-3(b). RE: MICHIGAN MEDICAL SERVICE

Be It Resolved, that the House of Delegates of the Michigan
State Medical Society liquidate the Michigan Medical Service
Plan as and when the present contracts terminate.

The Speaker : That resolution will be referred to

the Reference Committee on Reports of The Council.

louR. M.S.M.S.

PROCEEDINGS HOUSE OF DELEGATES— 1941

V-3(c). RE: MICHIGAN MEDICAL SERVICE

Donald R. Brasie, M.D. :

Be It Resolved, that no policy or policies of Michigan Med-
ical Service be sold to any married person having an annual
income above $2,000.00 and any single person having an annual
income above $1,000.00.

The Speaker: This resolution will be referred to the
Reference Committee on Reports of the Council.

V-3(d). RE: MICHIGAN MEDICAL SERVICE

Donald R. Brasie, M.D. :

Be It Resolved, that the House of Delegates of the Michi-
gan State Medical Society instruct the officials and directors of
Michigan Medical Service to make no direct or indirect attempts
to sell, or in fact, to sell a policy or policies to persons em-
ployed in those counties in which the component county society
is opposed to such action.

The Speaker: This resolution will be referred to

the Reference Committee on Reports of The Council.

V-3(e). RE: MICHIGAN MEDICAL SERVICE

Donald R. Brasie, M.D. :

Be It Resolved, that the personnel, principles and practices
of the sales organization of the Michigan Medical Service Plan
in any given county be under the direct supervision of that
county medical society.

The Speaker: This resolution will be referred to

the Reference Committee on Reports of The Council.

VI-2. CONSTITUTION, ARTICLE III, SECTION
4, RE: HONORARY MEMBERS

C. L. Hess, M.D. (Bay-Arenac-Iosco) : I have sev-

eral resolutions that concern the Constitution and By-
Laws, the object being to clarify certain sections and
improve others.

Whereas, the Constitution in Article three (III), Section four
(4), provides for Honorary Members of the State Society but
does not state whether or not they shall pay dues, vote, or
hold office.

Be it resolved, that Article three (HI), Section four (4) of
the Constitution have added the following sentence;

“Honorary Members shall pay no dues to the State Society
and shall be without right to vote or hold office in either County
or State Society.”

The Speaker: This amendment to the Constitution

will be referred to the 1942 Session of the House of
Delegates.

VI-3. CONSTITUTION, ARTICLE IV, SECTION
3, RE: OFFICERS AND THE HOUSE
OF DELEGATES

C. L. Hess, M.D. :

Whereas, Article four (IV), Section three (3) of the Constitu-
tion provides that officers of the Society and members of The
Council shall be members of the House of Delegates, and where-
as, Past Presidents can be made members of the House of
Delegates only by replacing other desirable delegates in Annual
County Society Elections, and whereas. Past Presidents should
be members to make more certain the continued benefit of their
wisdom and experience in the House of Delegates,

Therefore, be it resolved, that Article four (IV), Section
three (3) of the Constitution have added the following sentence:

The past presidents shall be members at large of the House of
Delegates during the first five (5) years of their past presidency
with right to vote and hold office.”

The Speaker: This resolution will be referred until
the 1942 Session of the House of Delegates.

November, 1941

VI-4. CONSTITUTION, ARTICLE IV, SECTION

5, RE: ELECTIONS BY THE DELEGATES

C. L. Hess, M.D. :

Whereas, Article four (4), Section five (S) of the Constitu-
tion states that the House of Delegates shall elect certain offi-
cers, Council members, American Medical Association delegates,
and further, such other officers as the House may require, and
whereas, in this section Delegates to the American Medical As-
sociation might be classified as officers.

Be it resolved, that Article four (4), Section five (5) be re-
arranged to read as follows:

“The House of Delegates shall at the regular annual session,
elect the President-elect, a Speaker, and Vice Speaker of the
House of Delegates, Members of The Council, and such other
officers as may be created by the House of Delegates, unless
otherwise specified in the Constitution and By-Laws. It also shall
elect delegates and Alternate Delegates to the American Medi-
cal Association.”

The Speaker: This amendment to the Constitution

will be referred until the 1942 Session.

VI-5. CONSTITUTION, ARTICLE X,
SECTION 1

RE: CLARIFICATION OF “SESSION” AND
“MEETING”

C. L. Hess, M.D. :

Whereas, the House of Delegates has now under considera-
tion an amendment clarifying the words “Session” and “Meet-
ing”;

Be it resolved, that contingent to the adoption of this amend-
ment Article ten (10), Section one (1), 3rd sentence, of the Con-
stitution have the word “Session” changed to “Meeting” and
read as follows:

“A majority of all the members present at that meeting shall
determine the question and be binding.”

C. L. Hess, M.D. : Instead of saying “a majority of
members present at that Session.”

The Speaker: This shall be referred to the 1942
Session.

VI-6. BY-LAWS, CHAPTER 3, SECTION 1, RE:
CLARIFICATION OF “MEETING” AND
“SESSION”

C. L. Hess, M.D. :

“Chapter 3 — Section 1 ; “The House of Delegates shall meet
annually at the time and place of the Annual Session and may
hold such number of Meetings as the House may determine or
its business require, adjourning from day to day as may be
necessary to complete its business and specifying its own time
for the holding of its Meetings.”

VI-7. BY-LAWS, CHAPTER 3, SECTION 7-L,
CHANGING WORD “SESSION” TO
“MEETING”

“Chapter 3, Section 7, Paragraph L, 1st sentence: “No new

business shall be introduced in the last meeting of the House
of Delegates without the unanimous consent of the delegates, ex-
cept when presented by The Council.”

The Speaker: This will be referred to the Com-

mittee on Amendments to the Constitution and By-Laws.

VI-8. BY-LAWS, CHAPTER 3, SECTION 2, RE:
QUALIFICATIONS OF HOUSE OF
DELEGATES

C. L. Hess, M.D. :

Whereas, Chapter three (3), Section two (2) of the By-
Laws requires two (2) years membership for a delegate and
whereas, he should be an active member.

Be it resolved, that Chapter three (3), Section two (2), of
the By-Laws be amended to read as follows:

“A Delegate must have been an active member of the So-
ciety for at least two (2) years preceding his election.”

The Speaker: This will be referred to the Refer-

ence Committee on Amendments to the Constitution and
By-Laws.

903

PROCEEDINGS HOUSE OF DELEGATES— 1941

VI-9. CONSTITUTION, ARTICLE III,
SECTIONS 3 AND 5, RE: ASSOCIATE
AND JUNIOR MEMBERSHIPS

C. L. Hess, M.D. :

Whereas, Article three (III) of Section three (3) of the
Constitution provides Junior Membership for interns, and Sec-
tion five (5) of the same article provides Associate Member-
ship for interns, and

Whereas, -when these Sections were adopted the Associate
Membership provision had been recommended,

Be it resolved, that Article three (III), Section three (3)
of the Constitution, referring to Junior Membership be deleted
and the subsequent sections numbered 4 to 8 in Article three
(III) be numbered 3 to 7, respectively.

The Speaker: This will be referred to the 1942 Ses-
sion of the House of Delegates.

VI-10. BY-LAWS, CHAPTER 5, SECTION 1,
RE: ANNUAL MEETING OF THE
COUNCIL

C. L. Hess, M.D. :

Whereas, The fourth sentence of Chapter five (5), Section
one (1) of the By-Laws reads as follows;

“Its annual meeting shall be held coincident with the annual
meeting of the Society.”

Whereas, This sentence conflicts with the time of the an-
nual meeting of The Council in January as provided in the
Constitution, Article eight (VIII), Section two (2);

Be It Resolved, that the above fourth sentence of Chapter
five (5), Section one (1) of the By-Laws be deleted.

The Speaker: That will be referred to the Refer-

ence Committee on Amendments to the Constitution and
By-Laws.

C. L. Hess, M.D. : I have two resolutions that should
be adopted together, one to the Constitution and one to
the By-Laws.

The Speaker: You can’t do that. Doctor. The other
one cannot be handed in until next year.

C. L. Hess, M.D. : I think in this case the By-Law
can be adopted this year, if acceptable to the dele-
gates, without conflicting with the Constitution.

VI-11. CONSTITUTION, ARTICLE V, SECTION
1, RE: OFFICERS AND THE COUNCIL

C. L. Hess, M.D. :

Whereas, Article V of Section 1 of the Constitution provides
in the third sentence that the President, the President-Elect, the
Secretary and the Treasurer shall be members of The Council
but in the fifth sentence denies their right to vote.

Be it resolved, that these fifth and sixth sentences of Article
V, Section 1 be deleted, which read as follows:

“The President, the President-elect, the Secretary and the
Treasurer shall be ex officio members and without right to vote.
The Speaker of the House of Delegates shall be a member of
The Council and of its Executive Committee with power to
vote.”

C. L. Hess, M.D. : That last sentence is taken care
of in the next resolution. In that case the wording of
the article is such that the officers mentioned are mem-
bers of the Council, with right to vote.

The Speaker : That will be referred to the 1942

Session of the House of Delegates.

VI-12. BY-LAWS, CHAPTER 5, SECTION 1, RE:
EXECUTIVE COMMITTEE OF THE
COUNCIL

C. L. Hess, M.D. :

Whereas, Chapter 5, Section 1 of the By-Laws refers to
elections in the Council,

Be It Resolveui, that the third sentence of Chapter 5, Sec-
tion 1 of the By-Laws be changed to read as follows:

“It shall elect to serve one year, its Chairman, Vice-Chairman,
Chairman of the Finance Committee, Chairman of the County
Societies Committee, and Chairman of the Publication Commit-
tee, who with the President, the President-Elect, the Secretary
and the Speaker of the House of Delegates shall constitute
the Executive Committee, and

Be It Resolved, that the last sentence of this Section 1
of Chapter 5 be deleted, referring to the appointment of an
Executive body.

The Speaker: This resolution will be referied to >

the Reference Committee on Amendments to the Con- f
stitution and By-Laws.

t

V-4. RE: ELECTION OF DELEGATES TO
A.M.A.

Wm. S. Reveno, M.D. (Wayne) : I have a resolu-

tion that is designed to balance the election of the num-
ber of delegates to the American Medical Association.

Be it resolved, that in order to balance the number of dele-
gates and alternates to be voted on each year, one of the four
A.M.A. Delegates whose terms expire in 1942, viz.: Drs. Luce,
Gruber, Reeder or Keyport be asked to resign (with the assur-
ance of reelection), and immediately be reelected for a term of
two years. The Speaker is to draw the name of the delegate
selected as the martyr. In this manner two delegates will be
voted on at this year’s meeting and three at the next.

The Speaker: This resolution will be referred to

the Reference Committee on Resolutions.

VI-13. BY-LAWS, CHAPTER 3, SECTION 7(d)
RE: ELECTION OF DELEGATES AND
ALTERNATES TO A.M.A.

Wm. S. Reveno, M.D. :

“It shall elect Delegates and Alternate Delegates to the
American Medical Association in accordance with the regulations
of that parent organization.

“The number of alternate delegates shall equal the number
of delegates to the American Medical Association. Delegates
and Alternates shall hold office for two years.

“At each annual election, candidates for delegates and alter-
nates shall be nominated in number equal to or greater than
the number to be elected. Election shall be by ballot. The
required number of high candidates shall be declared elected.

“In case of a tie vote between any number of high can-
didates, the Speaker and Vice-Speaker shall vote on the two
candidates alphabetically first, each filling out a secret ballot,
one of which shall be drawn at random by the chief teller.
The defeated candidate shall then be paired with the next
alphabetically following candidate and ballots cast in the same
manner. This process is to be repeated until all ties have been
resolved.

“Alternate delegates shall have relative seniority according to
the respective number of votes received by them, and such
seniority rank shall be designated at the time of election. Alter-
nate delegates serving their second year in office shall hold
seniority over those alternates serving their first year in office.

“Any vacancies caused by failure or inability of any dele-
gates to attend shall be assigned to alternate delegates in the
order of their seniority as defined in this section.”

The Speaker: This proposed amendment to the

By-Laws will be referred to the Reference Committee
on Amendments to the Constitution and By-Laws.

V-5. RE: PROFESSIONAL LIAISON
COMMITTEE

Allan McDonald, M.D. (Wayne) ;

Whereas, in unity there is strength, and

Whereas, the allied professions of Dentistry, Pharmacy and
Medicine have much in common and their conduct toward the
public is guided by similar ethics; and

Whereas, the experience in Wayne County during the past
two years has demonstrated the value of the collaboration of
these groups;

Be it resolved, that the House of Delegates of the Michigan
State Medical Society request their Executive Council to ap-
point a committee of three members to be known as the “3 D’s
Liaison Committee” (Doctors, Druggists and Dentists), and that
The Council further contact the Michigan State Dental Society
and the Retail Druggists Association asking them to appoint
similar committees to the end that: (a) A feeling of unity

and mutual understanding be developed; (b) That useful infor-
mation may be quickly and accurately imparted; (c) That aid
may be promptly given in finding solutions to problems of these
groups (both professional and economic); (d) That desirable
legislation may be fostered; and (e) That pernicious legislation
may be more effectively combatted, all for the public good.

The Speaker : This resolution will be referred to

the Reference Committee on Resolutions.

Jour. M.S.M.S.

904

PROCEEDINGS HOUSE OF DELEGATES— 1941

V-f). RE: SECTION ON GENERAL PRACTICE

Henry A. Luce, M.D. (Wayne) :

Whereas, sixty-six and two-thirds per cent (66^%) of the
doctors of medicine of this state are general practitioners, and
these general practitioners constitute the bulk of the member-
ship of the Michigan State Medical Society, and

Whereas, General Practice is an entity of and by itself within
the profession, is definite in its comprehension and limitless in
its extension, and

Whereas, no place has been provided on hospital staffs
through which General Practitioners would be enabled to submit
their evidence of special training in certain fields of medicine
and surgery which would qualify them before the public as
proficient therein, and

Whereas, General Practitioners have a special interest in
medical legislation, administration and jurisprudence, which
justifies their particular voice being officially heard, and

Whereas, it is not the desire of the General Practitioner to
disrupt the splendid variety and calibre of scientific programs
of the M.S.M.S. but rather to create a new and proper basis
for separate registration, representation and participation in the
general activities of the organization, and

Whereas, the people of the state will be inclined to view
with favor and good will the official recognition of their family
physicians as a distinct part of the Michigan State Medical
Society, and

Whereas, the specialty fields are overcrowded with general
practitioners classified as specialists only because there is no
proper classification for them, and

Whereas, the establishment of an official Section on General
Practice in the M.S.M.S. will stimulate a more active interest
and cooperative attitude among the profession generally, making
far greater unity in the advancement of the organization’s pro-
grams, and

Whereas, The Coupcil of the Wayne County Medical Society
has gone on record as endorsing the introduction of these res-
olutions for the creation of a Section on General Practice of
the M.S.M.S., and

Whereas, efforts to date looking toward the creation of an
official section of General Practitioners in the A.M.A. have met
with approval for a trial period of one year;

Therefore, be it resolved, that the House of Delegates of
the M.S.M.S. take action at this time to create a new Section
on General Practice to be duly constituted of equal rank and
authority with the other sections already established.

The Speaker ; This resolution will be referred to
the Reference Committee on Resolutions.

V-2. RE: SPECIAL MEMBERSHIPS

L. G. Christian, M.D. (Ingham) :

Whereas, Doctors E. G. McConnell, C. V. Russell and H. S.
Bartholomew have fulfilled all the requirements for Retired
Membership in the Michigan State Medical Society,

Be it resolved, that the House of Deleg*ites of the M.S.M.S.
be instructed to authorize the Executive Office of the Michigan
State Medical Society to place the names of Doctors McConnell,
Russell and Bartholomew on its Retired Membership roster.

The Speaker: This resolution will be referred to
the Reference Committee on Resolutions.

V-7. RE: NATIONAL PHYSICIANS’
COMMITTEE

L. G. Christian, M.D., read resolution regarding
National Physicians’ Committee.

Whereas, one of the most important functions of the medi-
cal profession on behalf of the public today is to apprise them
of the true status of the medical services available to them, the
accomplishments of those services in the past, and the neces-
sity that those services be kept free from political control in
the future ; and

Whereas, The National Physicians’ Committee for the Ex-
tension of Medical Service has been organized by our national
leaders for just this purpose.

Therefore, be it resolved, (1) that the Michigan State Medi-
cal Society hereby approve the program and proposed activities of
the National Physicians’ Committee for the Extension of Medical
Service; and

(2) that the county societies comprising the Michigan State
Medical Society are hereby urged to further the work of the
National Physicians’ Committee by an aggressive campaign to
solicit funds and to acquaint every member of the profession
with the necessity for such a program of public education.

The Speaker: This resolution will be referred to
the Reference Committee on Resolutions.

November, 1941

V-2. RE: SPECIAL MEMBERSHIPS

Harry F. Dibble, M.D. (Wayne) :

The Wayne County Medical Society takes pride in recom-
mending for Emeritus Membership the following distinguished
physicians who have served the profession and the society with
honor for many years; they all have been in the practice of
medicine for fifty years or more and members of the State
Society for at least twenty-five years:

Charles D. Aaron, M.D., Detroit, Michigan
Angus L. Cowan, M.D., Detroit, Michigan
Gilbert S. Field, M.D., Detroit, Michigan
George E. Frothingham, M.D., Detroit, Michigan
Wm. C. Martin, M.D., Detroit, Michigan
Irwin H. Neff, M.D., Detroit, Michigan

G. L. Renaud, M.D., Detroit, Michigan
Walter R. Parker, M.D., Detroit, Michigan
Joseph E. G. Waddington, M.D., Detroit, Michigan

The Wayne County Medical Society recommends that the
following two physicians be placed on the Retired Membership
rolls; they no longer are engaged in the practice of medicine:
Edward P. Newton, M.D., Detroit, Michigan

H. J. Hammond, M.D., Detroit, Michigan

The Speaker : This resolution will be referred to
the Reference Committee on Resolutions.

V-8. RE: PREMARITAL INSTRUCTION

C. F. DeVries, M.D. (Ingham) :

Whereas, the family forms the basic structure of our Ameri-
can Civilization and culture; and

Whereas, it is felt that with present trends of education
and human interest there exists an ever-increasing need and
demand for the establishment of the family upon a basis of
true understanding, normal relationships between husband and
wife, mutual responsibilities to be assumed; and

Whereas, young men and women assume marital responsibili-
ties with little or no knowledge of the fundamental basis there-
of; and

Whereas, the divorce rate among American people has shown
an alarming rate of increase during the past two decades, par-
tially because of this lack of understanding; and

Whereas, it is felt that whenever possible premarital instruc-
tions should be made available to those contemplating marriage,
and further that postmarital assistance and guidance should
be similarly available to those already married; and

Whereas, the medical profession in general constitutes that
group of society best qualified to furnish factual information
concerning the physical relationships and responsibilities of mar-
riage, though responsibility for the dissemination of such infor-
mation has not always been accepted by the physicians.

Therefore, be it resolved, that the House of Delegates of
the Michigan State Medical Society recommend that those antici-
pating marriage be advised and encouraged to seek consultation
and advice concerning these matters from their family physicians,
preferably upon the occasion of examination for certification for
marriage licensure; and

Be it further resolved, that physicians be requested to co-
operate and prepare themselves to offer considerate and kindly
guidance to those seeking such advice; and

Be it further resolved, that while it is appreciated that this
friendly counsel will require some time on the part of the
physician, new families will bring added grateful patients to
such physician’s practice, and that in view of this, fees com-
mensurate with the economic status of the individual be charged
for such consultation and advice.

The Speaker: This . resolution will be referred to
the Reference Committee on Standing Committees.

V-3(f). RE: MICHIGAN MEDICAL SERVICE

S. W. Insley, M.D. (Wayne) :

Whereas, Michigan Medical Service is a movement of Na-
tional significance and of great sociological value, and

Whereas, Michigan Medical Service was expected to go
through a period of stress and strain, and

Whereas, it now appears that new and different approaches
may be used to make the service plan even more workable.
Therefore, be it resolved, that the House of Delegates of
the Michigan State Medical Society, representing the physicians
of Michigan, recommend that Michigan Medical Service take im-
mediate steps towards study and placement in test operations
(for comparative purposes) such new approaches as might be
generally described as “limited liability” service contracts. These
new approaches should also take up for reconsideration the
limiting of benefits, increased subscription rates and control of
distribution.

The Speaker: This resolution will be referred to
the Reference Committee on Reports of The Council.

905

PROCEEDINGS HOUSE OF DELEGATES— 1941

V-9. RE: TRAINING OF MEDICAL
TECHNICIANS

R. H. Pino, M.D. (Wayne) :

Whereas, emphasis during the past several years on insuf-
ficient distribution of medical care is now further stressed
because the absorption of doctors of medicine into the Govern-
ment service, provides a strategic time for such emphasis, and.

Whereas, taking advantage of this various inadequately trained
groups are increasingly striving for recognition, claiming that
they can fulfill the requirements for giving health care, not only
to the civilian population, but in the Army, Navy, and Air
Corps, and.

Whereas, capitulation to such requests would definitely retard
for years to come the high standards attained in medical edu-
cation and in medical care to the American people, and.

Whereas, the medical schools this year are increasing their
enrollment by ten per cent to meet any ultimate deficiencies,
and.

Whereas, the training of technicians to work under the direc-
tion of the doctor of medicine in our hospitals and in our
laboratories and offices are proving to be a most helpful and
efficient aid in the distribution of medical care, thus making it
possible for more people increasingly to have the counsel and
service of each doctor of medicine, and thus maintaining the
high standards of medicine and the more complete distribution
of medical care.

Therefore, be it resolved, that the House of Delegates of
the Michigan State Medical Society representing the medical
profession of Michigan, petition the American Medical Asso-
ciation through its House of Delegates that at their next annual
meeting they take a positive stand not to capitulate to pressure
groups who urge recognition of such indequately trained groups
asking support and ethical recognition by the A.M.A.

Be it further resolved, that the Council on Medical Edu-
cation and hospitals, and the Bureau of Medical Economics of
the A.M.A., from the standpoint of education and increased
distribution of medical care, be urged to make further study
of the possibilities of the training of medical technicians in the
various specialties, to work under the guidance of doctors of
medicine in order that the privilege of medical care may
come to more people through the increased assistance afforded
the doctor of medicine.

Be it further resolved, that copies of this resolution be
sent to the Headquarters of the A.M.A. in Chicago, to each
member of the Michigan Delegation to the A.M.A., and that
the Michigan delegates be instructed to introduce such a resolu-
tion to that body at the next annual meeting and also that
copies be sent to the various state societies and they be urged
to take similar steps in instructing their delegates.

The Speaker: This resolution will be referred to
the Reference Committee on Officers’ Reports.

V-3(g). RE: MICHIGAN MEDICAL SERVICE

C. T. Ekelund, M.D. (Oakland) ;

Whereas, the first 18 months of operation of Michigan Medi-
cal Service has exacted a devotion of time and talent by its
President and Executive Committee equal to that of the execu-
tives of a large insurance company, and

Whereas, Michigan Medical Service is, in point of fact, an
insurance program.

Therefore, be it resolved, that the House of Delegates of
the Michigan State Medical Society recommend that qualified
executive personnel with administrative training and experience
in the insurance field be added to promote efficient operation
and make possible the collection of sound actuarial statistics,
and

Be it further resolved, that a doctor of medicine be sought
to serve as Medical Director preferably one from within the
ranks of the Michigan State Medical Society.

The Speaker: This resolution will be referred to
the Reference Committee on Reports of The Council.

Are there any more resolutions? If not, we will
proceed to the next order of business, the reports of
standing committees. First will be the Legislative Com-
mittee, Dr. Miller.

VII. Reports of Standing
Committees

VII-l. LEGISLATIVE COMMITTEE

H. A. Miller, M.D. : Mr. Speaker and Members of
the House of Delegates : Your Legislative Committee’s
report is found in the Handbook on page 48. There
is very little to add.

I would bring your attention to some of the recom-
mendations as made by the committee. You will note
that during the year there were a number of bills
that were considered, but no legislation passed during
the last legislature inimical to the practice of medicine.

There is a particular recommendation made that I
would invite to your attention, in regard to county
medical societies acknowledging and helping the legis-
lator in his work, showing him that you appreciate his
activity. I have a letter from a small county, which
I will not read in detail, a county society of sixteen
active members, which held a meeting with thirteen
members present. I will read just a portion of the
letter, which states :

“Our Legislator was then presented with a solid
gold, twenty-one jewel Lord Elgin wrist watch suit-
ably engraved.”

On June 13, as is customary, wt sent letters from
Lansing to various legislators who have helped us dur-
ing the year. In one paragraph of this letter I, as
Chairman of the Legislative Committee, stated:

“I shall do my utmost to transmit this appreciation
and sense of gratitude to every one of the 6,142 doc-
tors of medicine in Michigan, with the hope that these
thanks will be more tangibly expressed in the future.”

I believe the resolutions that have been presented
here to thank all those who have aided in legislation
during the last year are true expressions of our ap-
preciation for good legislation.

Personally, I want to thank the members of my com-
mittee, the members of The Council, the members of
the State Society, and everyone who has aided in our
work this past year.

The Speaker: The report of the Legislative Com-
mittee will be referred to the Committee on Reports of
Standing Committees.

The next will be the Committee on Distribution of
Medical Care, Dr. Conover.

VII-2. COMMITTEE ON DISTRIBUTION OF
MEDICAL CARE

T. S. Conover, M.D. : Mr. Speaker and Members of
the House of Delegates : The Committee on Distribu-
tion of Medical Care draws to your attention a change
or an addition to paragraph 3 of its report as pub-
lished, and that is in the resolution concerning general
practitioners.

The Speaker: The report of the Committee on Dis-
tribution of Medical Care will be referred to the Ref-
erence Committee on Reports of Standing Committees.

VII-3. MEDICAL-LEGAL COMMITTEE

T. E. Hoffman, M.D. : In the absence of the Chair-
man, I wish to report that the Medical-Legal Commit-
tee report stands as given on page 58 of the Hand-
book.

The Speaker : The report of the Medical-Legal

Committee will be referred to the Reference Commit-
tee on Reports of Standing Committees.

VII-4. REPRESENTATIVES TO THE JOINT
COMMITTEE ON HEALTH EDUCATION

Burton R. Corbus, M.D. : Mr. Speaker, there are
no additions to the report as given in the Handbook.

The Speaker : The report of this committee will be
referred to the Reference Committee on Standing Com-
mittees.

VII-5. PREVENTIVE MEDICINE
COMMITTEE

The Speaker: Next will be the report of the Pre-
ventive Medicine Committee which is found in the
Handbook on page 61 and will be referred to the
Reference Committee on Standing Committees.

Jour. M.S.M.S.

906

PROCEEDINGS HOUSE OF DELEGATES— 1941

VII-6. CANCER COMMITTEE

The Spe-\ker: This report as published on page 70
of the Handbook will be referred to the Reference
Committee on Standing Committees.

VII-7. MATERNAL HEALTH COMMITTEE

i Wm. S. Re\'e;no, M.D. : Dr. Seeley has asked me
to announce that Dr. Campbell is reading a detailed
report on Friday at nine-thirty before the Section on
Obstetrics and Gjmecolog^', entitled “Facilities and Prac-
tices in Licensed Maternity Hospitals and Homes in
Michigan.”

The Speaker; The remainder of this report will
be found in the Handbook on Page 82, and the report
will be referred to the Reference Committee on Stand-
ing Committees.

I VII-8. SYPHILIS CONTROL COMMITTEE

! The report of the Syphilis Control Committee is also
found in the Handbook on page 84 and will be referred
to the Reference Committee on Standing Committees.

VII-9. TUBERCULOSIS CONTROL
COMMITTEE

This report is found in the Handbook on page 89
and will be referred to the Reference Committee on
i Standing Committees.

VII-10. INDUSTRIAL HEALTH COMMITTEE

; Henry Cook, M.D. : There are one or two points
that I would like to stress in this work.

The pioneer work of this committee started about
two 3'ears ago. Certain matters have developed which
we feel are important to the medical profession as a
whole.

I would like to say that in our first meeting, the
members of the committee had the feeling that the
subject of industrial health had to do with those prob-
lems which were incident to emplojanent. But in the
program of industrial health, we wish to emphasize
the fact as it is in the Handbook, that lost time in
industry, 93 per cent last year in General Motors and
about 90 per cent in all of industry’, is due to non-
occupational diseases and accidents which are the direct
concern of the medical profession as a whole.

We also wish to invite your attention to the fact
that over 60 per cent of industry- in the State of Michi-
gan is in plants of 500 or less. In the larger indus-
tries, the problems of industrial health are ver^’ well
handled.

We also wish to invite j'our attention to the fact
that if this problem is to be handled adequately', it is
going to be handled by the cooperation of the medical
profession, generally the family physicians, together with
the employers and the manufacturers’ association of the
state. We have established relationships with the manu-
facturers’ association, so that it is now willing to go
ahead with the program as fast as we in the profes-
sion are ready to do it. We had meetings with the
manufacturers’ association which promised to contact
] the local associations, and through them, the medical
! profession in those communities, to work out a pro-
; gram of industrial health as the doctors would like to
I have it, and they are not going to dictate the manner
( of procedure.

j Therefore, we have recommended an effort on an
I experimental basis in two counties in the state. One
j has it already in effect : another one has it under con-
j sideration. We hope to establish examples of indus-
; trial health cooperation and care, which may be fol-
lowed by other counties.

[ If this comes up in j'our counties, we would like to
i urge that you give serious consideration to it. We must
; break down this feeling of the profession that the

' Rw'ember, 1941

problem of industrial health is a problem of the indus-
trial physician. His job is case finding only. Ninety
per cent of the lost time is j'our problem, the care
of your private case.

We would like to urge you to keep that in mind
and give it your consideration. W'e have nothing fur-
ther to report, but it did seem to me important enough
to bring that to your attention, in order that the prob-
lem may be better understood.

The Spe.\ker; The report of the Industrial Health
Committee will also be referred to the Reference Com-
mittee on Reports of Standing Committees.

VII-11. MENTAL HYGIENE COMMITTEE

Henry A. Luce, M.D. : Mr. Speaker, one of the
very' best reports in the Handbook will be found on
page 94. It is recommended for your attention.

The Speaker; This will be referred to the Reference
Committee on Standing Committees.

VII-12. CHILD WELFARE COMMITTEE

Frank VanSchoick, M.D. ; Mr. Speaker and Mem-
bers of the House of Delegates ; This report is on
page 73 of your Handbook. However, I wish to put
a little between the lines, to guide you a bit in the
future.

M e have had two main activities in the past y'ear.
The first, as you well know, was cooperation with
the Legislative Committee in formulating proposed legis-
lation relative to the crippled and afflicted child. This
entailed a tremendous amount of work. As you have
already' heard from the Legislative Committee, there
was tremendous cooperation from all groups involved,
not only the professional groups, but various lay groups
which were contacted. We tried to formulate legis-
lation which would bring and keep the practice of
medicine, as it affected children, in the hands of the
profession, where it belonged.

The other matter that I wish to bring to y'our atten-
tion is that this committee cooperated with several
other agencies, state and lay', for the furtherance of
medical knowledge throughout the state.

We have cooperated with the State Health Depart-
ment, advised them as to the conduct of immunizing
procedures throughout the state, kept immunizing proce-
dures up to date, in light of the best accepted medical
practice at the time.

We have prepared brochures on measles. There is
one in process of preparation on whooping cough. Most
of you recall having seen the one on measles which
the epidemic this year called forth.

We have cooperated with the State Health Depart-
ment and the ^Maternal Health Committee of this So-
ciety in furthering education on the care of the pre-
mature infant, and distributed incubators. We have had
tremendous interest in the technical side of the manu-
facture of these incubators, and we feel that a really
thorough, good job has been done.

The Speaker; The report of the Committee on Child
Welfare will be referred to the Reference Committee
on Standing Committees.

VII-13. IODIZED SALT COMMITTEE

Frederick B. Miner, ^I.D. ; Mr. Speaker and Dele-
gates ; This is the nineteenth annual report of the
Iodized Salt Committee. We have held but one meet-
ing this year, due to the inactivity in Washington.

As you know, our Michigan Iodized Salt Committee
has been before the Federal Food and Drug Adminis-
tration for over a year, fighting more or less, but living
in a state of doubt, not knowing what was going to
be done to it.

At the time of our annual meeting last year, cer-
tain regulations had been published in the Federal
Register, and a hearing was going on. We did not

907

PROCEEDINGS HOUSE OF DELEGATES— 1941

introduce testimony until a representative of the Drug
Division of that Administration introduced such poor
testimony that we felt testimony should be introduced
from Michigan. Consequently, on October 25, a twenty-
five-page article of testimony was read by your Chair-
man at the hearing. This was compiled by a lawyer
from the General Foods Corporation and a lawyer
from the Salt Producers Association, also Mr. Wilcox,
Chairman of the Standardization Committee of the Salt
Producers Association, and myself.

Since our annual report was submitted for publica-
tion in your Handbook, the Federal Register of July 8
came out with final regulations on iodized salt. I am
happy to say that the Michigan delegation has won
two of its three points that it presented to the Federal
Food and Drug Administration. An exception was made
to iodized salt, giving us the liberty to use the iodine
content that we advocate ; also, the warning which they
proposed putting on the label has been annulled. Noth-
ing was said in the final regulations. However, we did
lose the point that we contended for, publishing on the
label the certificate which this Society granted your
Iodized Salt Committee in 1923. No statement can be
permitted on the label, of any therapeutic recommenda-
tion, and the poor customer who buys salt and asks
the clerk waiting upon her why salt is iodized, may
get an answer such as I did in North Branch, “It is
because it is more sanitary.” Canada has eliminated any
therapeutic statement on its iodized salt.

No appeal was submitted to the final regulations, so
that the regulations as published in the Federal Register
of July 8 stand as an integral part of the Food, Drug
and Cosmetic Act of our United States Government.

I want to invite your attention to another feature
that we have been able to do this last year, which
is to establish a national committee under the auspices
of the American Public Health Association. This is
a subcommittee under the Subcommittee on Evaluation
of Administrative Practices of which Dr. Haven
Emerson is chairman. Your Chairman heads the new
Study Committee on Endemic Goiter.

A two-day conference was held in Detroit in June,
and a 125-page book of proceedings of that two-day
conference is being edited at present and will be
presented to the A.P.H.A. meeting next month in
Atlantic City. After that date and with their approval,
they will be available to our Michigan committee.

However, that committee has said very many com-
plimentary things about the work that Michigan has
done in this preventive field of endemic goiter, and
they have adopted, I may say, the Michigan plan of
surveys and the Michigan plan of conducting their
study in other states and in other localities through-
out the United States.

I also want to say that they adopted the Michigan
recommendation of reducing the amount of iodine from
.02 of one per cent to .01 of one per cent of potassium
iodide in the salt, providing that a suitable and effec-
tive stabilizer is used to maintain that iodine content
in the iodized salt.

The Speaker; The report of the Iodized Salt Com-
mittee will be referred to the Reference Committee on
Standing Committees.

VII-14. HEART AND DEGENERATIVE
DISEASES

The Speaker: This report will be referred to the
Reference Committee on Standing Committees.

VII-15. POSTGRADUATE MEDICAL
EDUCATION

The Speaker: This report as found in the Hand-
book will be referred to the Reference Committee on
Reports of Standing Committees.

VII- 16. ETHICS COMMITTEE

The Speaker : This report will be referred to the
Reference Committee on Reports of Standing Com-
mittees.

VII-17. PUBLIC RELATIONS COMMITTEE

The Speaker: This report will be referred to the
Reference Committee on Standing Committees.

Next is the report of special committees.

VIII. Reports of Special
Committees

VIII-l. NURSES TRAINING SCHOOLS
COMMITTEE

The Speaker: This report will be referred to the
Reference Committee on Reports of Special Commit-
tees.

VIII-2. MEDICAL PREPAREDNESS
COMMITTEE

VIII-3. CONFERENCE COMMITTEE ON
PRELICENSURE MEDICAL
EDUCATION

Burton R. Corpus, M.D. : There is nothing to re-
port on Medical Preparedness. We have met simply
for organization. No matters of policy have arisen,
and the work that has been done has been done by the
Chairman who acts as a liaison between the American
Medical Association.

The Prelicensure Committee I am somewhat embar-
rassed to report on. It, like the joint committees, has
delegates to a committee which I head. There is noth-
ing additional to report, but I do wish you would
read the report on page 26 of the Handbook, because
I see in the future of the Prelicensure Committee and
the opportunity that is given to collaborate with the
University of Michigan and Wayne University, the op-
portunity to come closer than we ever have before in
planning to do something to work out this serious prob-
lem of internship, and the problem which has come
before us of preparing men for licensure in the spe-
cialties.

The Speaker ; The reports of the Conference Com-
mittee on Prelicensure Medical Education and of the
Medical Preparedness Committee will be referred to
the Reference Committee on Reports of Special Com-
mittees.

VIII- 4. RADIO COMMITTEE

R. J. Mason, M.D. : In an attempt to acquaint part
of the radio public with some of the problems of
the medical profession, the Radio Committee, through
the cooperation of the county societies, has had twelve
broadcasting stations throughout Michigan carrying
weekly programs on medical topics. Twenty-four such
papers have been carried by these twelve stations.

These talks have been of fifteen minutes’ duration.
They have been given by a member of a local county
medical society who has been introduced as a mem-
ber of the Michigan State Medical Society, with his full
name and title, and the title of his address. Further
details are found in the Handbook, page 63.

The Speaker; The report of the Radio Committee
will be referred to the Reference Committee on Re-
ports of Special Committees.

VIII-5. ADVISORY COMMITTEE TO
WOMAN’S AUXILIARY

R. C. Jamieson, M.D. : Mr. Speaker, the Woman’s
Auxiliary required very little advice this year and,
accordingly, there was no meeting held. The entire
report is published in the Handbook on Page 92, and
there is no supplementary report.

908

Jour. ^^I.S.M.S.

PROCEEDINGS HOUSE OF DELEGATES— 1941

The Speaker: The report of this committee will be
referred to the Reference Committee on Reports of
Special Committees.

VIII-6. SCIENTIFIC WORK COMMITTEE

T HE Speaker : This report, as published in the Hand-
book on page 33, will be referred to the Reference
Committee on Reports of Special Committees.

We will now recess until three o’clock.

The meeting recessed at twelve-thirty o’clock.

Tuesday Afternoon Meeting

September 16, 1941

The second meeting convened at three-twenty o’clock.
The Speaker, O. D. StiyLer, M.D., presiding.

The Speaker: The second meeting of the House
of Delegates will now come to order.

Dr. Day, will you make a supplemental report?

Luther W. Day, AI.D. : Mr. Speaker, seated in

the House now are 94 members, duly constituted dele-
gates of the House of Delegates of the Michigan State
Medical Society, which constitutes a quorum. There
is no majority from any one county.

Mr. Speaker, there is a contention over one delegate.
This morning, A. B. Smith, M.D., who was a dele-
gate from Kent County, was unable to be here due
to sickness. I seated W. C. Beets, ?^1.D., as alternate.
This afternoon Dr. Beets is not here, but Dr. Smith
has risen from a sick bed and now seeks to be installed
as delegate. What is the ruling?

The Speaker: On page 108, Chapter 3 — House of
Delegates, Section 3, states :

“A delegate once seated shall remain a delegate through
the entire session and his place shall not be taken by any other
delegate or alternate, provided that in case of emergency the
House of Delegates may seat a duly accredited alternate from
his county society.”

In line with this section, I can see no other course
but that Dr. Smith would be denied a seat at this
afternoon’s meeting.

C. E. Dutchess, IM.D. (Waj-ne) : This appears to
be a clear cut case of emergency. I move that the
gentleman be seated.

The Speaker: I have made a ruling, and I will
welcome an appeal from my decision.

E. D. Spalding, ]\1.D. (WajTie) : I appeal from the
decision of the Chair.

T. K. Gruber, M.D. (M'ayne) : It says “the House
may seat a duly accredited alternate.” He is not an
alternate.

The Speaker: Is there a second to Dr. Spalding’s
motion ?

R. A. Springer, M.D. (St. Joseph) : I second it.

The Speaker: It has been moved and supported

that the decision of the Chair be appealed. Is there
any debate?

J. J. O’Meara, ^I.D., Vice Speaker, assumed the
chair.

The Vice Speaker: Gentlemen, there is a motion
before the house. What is your pleasure? Shall
the ruling of the presiding officer be upheld? All in
favor signify by the usual sign “aye” ; against “no.”
The motion is lost and the Speaker is overruled.

The Speaker resumed the chair.

The Speaker: In that case Dr. Smith will be seated.

If there are no objections, the report of the Creden-
tials Committee will be considered the roll call of
the afternoon meeting.

The next order of business is imfinished business.
Is there any unfinished business to come before the
House of Delegates at this time?

November, 1941

W. R. Young, M.D. (Van Buren) : Are resolutions
in order?

The Spea.ker: If j-ou wish to revert to the previous
order of business of offering resolutions, I will enter-
tain 3'our resolution. It can be considered as imfinished
business.

V-2. RE: SPECIAL MEMBERSHIPS

W. R. Young, M.D. :

Whereas, Wilbur Hoyt, !M.D., of Paw Paw, ilichigan, has
fulfilled the requirements for Membership Emeritus,

Be it resolved, that this House of Delegates accord him
^Membership Emeritus in the Michigan State Medical Society.

The Speaker: This resolution will be referred to
the Reference Committee on Resolutions. Is there any
other unfinished business?

VI-14. BY-LAWS, CHAPTER 4, SECTION 4,
RE: DUTIES OF SECRETARY

Be it resoliTd, that the second sentence of Chapter 4, Sec-
tion 4 of the By-Laws be deleted, which reads as follows:

“He shall be an ex-officio member of the executive committee
of The Council without a vote.”

The Speaker: This resolution will be referred to
the Reference Committee on Amendments to the Con-
stitution and By-Laws.

VI-15. BY-LAWS, CHAPTER 10, SECTION 1,
RE: CHANGE OF WORD “SESSION”

TO “MEETING”; ALSO “PRES-
ENT” TO “SEATED”

Be it resolved, that Chapter 10, Section 1, of the By-Laws,
first sentence be amended to read as follows:

“These By-Laws may be amended bj' a majority vote of the
delegates seated, after the proposed amendment is laid on the
table for one meeting.”

The Speaker: This resolution will also be referred
to the Reference Committee on Amendments to the
Constitution and Bt-Laws.

VI-16. UNFINISHED BUSINESS FROM 1940
HOUSE OF DELEGATES

The Speaker: We will also refer to the Reference
Committee on Amendments to the Constitution and
Bylaws the proposed amendments to the Constitution
and By-Laws from the 1940 House of Delegates.

IX. Reports of Reference
Committees

IX-l. ON OFFICERS REPORTS
(I, II, IV, AND V-9)

H. F. Dibble, !M.D., moved the acceptance of this
report.

“We recommend the acceptance of all the officers’ reports
and concur in all of their recommendations, especially the fund
for carrying on the postgraduate course made by the president.

The motion was regularly seconded, put to a vote
and carried.

The Speaker: The next item is the report of the
Reference Committee on Reports of The Council, Dr.
Spalding.

IX-2. ON COUNCIL REPORTS (III, AND
V-3a to V-3g INCLUSIVE)

E. D. Spalding, M.D. : Mr. Speaker, your commit-
tee met and reviewed the published report of The
Council, with their appended recommendations as to
action by this bod}’, and also the supplementary report
with two additional recommendations. The report
speaks for itself as to the enormous amoimt of work
that has been done by these men and certainly merits
the whole-hearted endorsement of all of us. The de-

909

PROCEEDINGS HOUSE OF DELEGATES— 1941

tails of this can be found in the Handbook and need
not be gone into at this time, but I will take up spe-
cifically the recommendations at the end of the report,
serially.

“With respect to the five original and two supplemental
Recommendations of The Council:

“1. Your committee suggests that the Secretary of the Michi-
gan State Medical Society send out letters of appreciation to
appropriate members of the Michigan Legislature, and in addi-
tion a similar letter to the Governor, for their courteous recep-
tion of members of the medical profession and thoughtful con-
sideration of medical and public health matters throughout the
year.”

E. D. Spalding, M.D., moved its adoption.

The motion was regularly seconded, put to a vote
and carried.

“2. We approve the State Society’s joining in the develop-
ment of a plan of rehabilitation or rejected draftees wherein
the physician-patient relationship is safeguarded, and suggest
the appointment of a special committee to study this problem,
with power to act.”

E. D. Spalding, M.D., moved its adoption.

The motion was regularly seconded, put to a vote
and carried.

“3. We suggest letters be sent urging the immediate study
and revision of welfare benefit schedules in those counties
where medical service is being rendered below cost.”

E. D. Spalding, M.D., moved its adoption.

The motion was regularly seconded, put to a vote
and carried.

“4. We approve the receiving and endorsing of the resolu-
tions from all the state’s fifty-five county medical societies
recommending renewal of the Charter of the Michigan State
Medical Society, and propose that appropriate action be taken
by the Secretary to effect this.”

E. D. Spalding, M.D., moved its adoption.

The motion was regularly seconded, put to a vote
and carried.

“5. This Committee adds its endorsement to the proposals
of the Special Committee appointed to clarify the election of
delegates and alternates to the American Medical Association.”

E. D. Spalding, M.D. : That recommendation is be-
fore you in the form of another resolution but it also
appears in The Council’s report. I move the adoption
of this recommendation of The Council.

The motion was regularly seconded, put to a vote
and carried.

E. D. Spalding, M.D. : Now to the two supplemental
recommendations of The Council given to you this
morning by them.

“6. We approve of aggressive action being taken by county
medical societies where needed, to secure the compliance of
County Social Welfare Boards with the Michigan Welfare Law
of 1939, before they draw up their annual budgets.”

E. D. Spalding, M.D., moved its adoption.

The motion was regularly seconded, put to a vote
and carried.

“7. We endorse the House of Delegates’ reaffirmation of the
authorization to The Council to levy assessments to a total of
$5.00 when needed.”

E. D. Spalding, M.D., moved its adoption.

The motion was regularly seconded, put to a vote
and carried.

E. D. Spalding, M.D. ; Mr. Chairman, I now move
the adoption of the report of The Council as a whole,
including its original recommendations and two sup-
plementary recommendations.

The motion was regularly seconded, put to a vote
and carried.

E. D. Spalding, M.D. : In addition to the report of
The Council, with its recommendations, there were a
group of resolutions presented to this reference com-
mittee from various county societies. I will take them
up in groups, depending on their context.

E. p. Spalding, M.D., read the report on resolutions
submitted by St. Clair and Genesee Countv Medical
Societies re request for dissolution of ?^Iichigan Med-
ical Service (see pages 20 and 22) and moved that said
resolutions be not adopted.

The motion was regularly seconded.

The Speaker: It has been moved and supported

that these two resolutions by St. Clair and Genesee
Counties, to the effect that Michigan Medical Service
be discontinued, be not adopted. Is there any debate?

Donald R. Br.\sie, M.D. : Mr. Speaker, the reason

Genesee introduced this resolution was to express their
dissatisfaction with the way Medical Service is now run.
I think I can honestly admit that they expected this
action on your part. However, for a great variety of
reasons that I don’t think it is necessary to go into
again, you have heard them —

E. D. Spalding, M.D. : Mr. Chairman, I rise to a
point of order. The motion before the house is that the
recommendation to discontinue Michigan Medical Serv-
ice be not adopted. We are not now concerned with
how it shall be conducted, if it is to be continued.

The question was called for.

Donald R. Brasie, M.D. : O.K. May I proceed to

discuss that point?

The Spe.-kker : You may proceed to discuss that

point, yes, in a reasonable length of time.

Donald R. Braisie, M.D. : Thank you. If the

Michigan Medical Service is to continue on the basis
of paying inadequate fees, at least in our county, on
patients from whom we have been receiving an adequate
fee, in good times like these, we cannot see why we
should substitute Michigan Aledical Service for an in-
surance form that at the present time is entirely sat-
isfactory to the members of our county society.

We were told by officials, officers and others, who
spoke to us, that, if we did not desire Michigan Medical
Service in our county, we did not have to have it.

E. D. Spalding, M.D. : Mr. Chairman, I regret in-

terrupting the speaker, as another point of order, I
suggest that, in view of the context of the discussion,
we go into executive session.

The Speaker: Is there a support?

The motion was regularly seconded.

Executive Session

The Speaker : Without calling for a vote, the Speak-
er will then declare the House to be in executive ses-
sion.

The House went into Executive Session, and subse-
quently adopted the Report of the Reference Commit-
tee, re The Council Reports and also the St. Clair
County Medical Society Resolution (Callery) and the
Genesee County Medical Society Resolution (Brasie
No. 1) concerning dissolution of Michigan Medical
Service.

The House, as a whole, considered the Genesee Coun-
ty Medical Society Resolution (Brasie No. 2) concern-
ing income limits of Michigan Medical Service, and
referred this Resolution to the membership of Michi-
gan Medical Service.

The House, as a whole, considered the Genesee Coun-
ty Medical Society Resolution (Brasie No. 3) concern-
ing limitation of presentation of Michigan IMedical
Service in certain counties, and adopted a motion that
this Resolution be tabled.

The House, as a whole, considered the Genesee Coun-
ty Medical Society Resolution (Brasie No. 4) concern-
ing supervision of Michigan Medical Service in indi-
vidual counties, and adopted a motion that this Reso-
lution be tabled.

The House, as a whole, considered the Inslej- Res-
olution concerning a study by Michigan Medical Serv-
ice of a limited liability certificate, amended the Reso-
lution, and adopted it as follows :

Whereas, Michigan Medical Service is a movement of na-
tional significance and of great sociological value, and

Jour. M.S.:M.S.

910

PROCEEDINGS HOUSE OF DELEGATES— 1941

Whereas, ^Michigan Medical Service was expected to go
through a period of stress and strain, and

M'hereas, It now appears that new and different approaches
may be used to make the service plan even more workable.
Therefore, be it resolved. That the House of Delegates of
the Michigan State Medical Society, representing the physicians
of Michigan, recommend that Michigan Medical Service study
(for comparative purposes) such new approaches as might be
generally described as “limited liability” service contracts and
place same into operation if and when deemed advisable.

The House, as a whole, considered the Ekelund Res-
olution concerning personnel of Michigan Medical Serv-
ice, and adopted it.

Thereafter, the House of Delegates arose from Exec-
utive Session.

The Speaker: We are now out of executive session.
(End of Executive Session)

We will now consider the report of the Reference
Committee on Reports of Standing Committees, Dr.
Myers.

IX-3. ON REPORTS OF STANDING
COMMITTEES

IX-3. LEGISLATIVE COMMITTEE (VII-1)

De.\n W. Myers, M.D. : Mr. Speaker, report of the
Reference Committee on Reports of Standing Commit-
tees. On the Legislative Committee’s report, your Com-
mittee on Reports of Standing Committees approves
the report of the Legislative Committee as published in
the Handbook.

I move the adoption of this resolution.

The motion was regularly seconded, put to a vote
and carried.

IX-3. DISTRIBUTION OF MEDICAL CARE
(VII-2)

Dean W. Myers, M.D. : Your Committee on Re-

ports of Standing Committees approves the reports of
the following committees, as published in the Hand-
book for Delegates: First, Committee on Distribution

of Medical Care. I move the adoption of their report.

The motion was regularly seconded, put to a vote
and carried.

IX-3. MEDICAL-LEGAL COMMITTEE
(VII-3)

De.\n W\ Myers, M.D. : The report of the Medical-

Legal Committee. I move the adoption of their report.

The motion was regularly seconded, put to a vote and
carried.

The Speaker : Gentlemen, without objection. Dr.

Myers will submit the Reference Reports on the Pre-
ventive Committee and its sub-committees, and several
other committees, and adopt the reports in toto.

Dean W. Myers, M.D. read the list of committees,
beginning with Joint Committee on Health Education
and ending with Committee on Ethics.

IX-3. JOINT COMMITTEE ON HEALTH
EDUCATION (VII-4)

IX-3. PREVENTIVE MEDICINE COMMITTEE
(VII-5)

IX-3. CANCER COMMITTEE (VII-6)

IX-3. MATERNAL HEALTH COMMITTEE
(VII-7)

IX-3. SYPHILIS CONTROL COMMITTEE
(VII-8)

IX-3. TUBERCULOSIS CONTROL COMMIT-
TEE (VII-9)

IX-3. INDUSTRIAL HEALTH COMMITTEE
(VII-10)

IX-3. MENTAL HYGIENE COMMITTEE
(VII-11)

IX-3. CHILD WELFARE COMMITTEE (VII-12)

November, 1941

IX-3. IODIZED SALT COMMITTEE (VII-13)

IX-3. HEART AND DEGENERATIVE DIS-
EASES COMMITTEE (VII-14)

IX-3. POSTGRADUATE MEDICAL EDUCA-
TION COMMITTEE (VII-15)

IX-3. ETHICS COMMITTEE (VII-16)

IX-3. PUBLIC RELATIONS COMMITTEE
(VII-17)

De.\n W. Myers, M.D. : I move the adoption of the
reports from these several committees.

The motion was regularly seconded, put to a vote
and carried.

IX-3. RE: PREMARITAL INSTRUCTION
(V-8)

Dean W. Myers, M.D. : On the next report, the
resolution as offered by Dr. DeVries, your committee
was not quite sure why that resolution was referred
to this committee, but we acted upon it anyhow, as
follows :

“Resolution on The Family offered by Dr. DeVries; Your
Committee on Reports of Standing Committees approves the
Resolution, except the last paragraph referring to fees charged
for such information and recommends that that paragraph be
deleted. We also recommend that the Resolution be referred
back to the House of Delegates to be considered further by
the Standing Committee on Preventive Medicine.”

De.\n W. Myers, M.D. : I move the adoption of this
report, Mr. Speaker.

The motion was regularly seconded, put to a vote
and carried.

“Your Committee further recommends that the House of
Delegates extend to the committees and their individual mem-
bers its appreciation for the excellent work done during the
year and advise that all members carefully study the reports as
published in the Handbook, to the end that the Society’s member-
ship shall be better informed on the work done and ends accom-
plished and consequently be better prepared to render effective
assistance in carrying forward the aims and objects of the
Michigan State Medical Society.”

Dean Myers, M.D., moved its adoption.

The motion was regularly seconded, put to a vote
and carried.

Dean W. Myers, M.D. : Mr. Speaker, I move the

adoption of the entire report.

The motion was regularly seconded, put to a vote
and carried.

The Speaker: Our next order of business will be

the report of the Reference Committee on Reports of
Special Committees.

IX-5. ON REPORTS OF SPECIAL
COMMITTEES

Geo. H. Southwick, M.D. : Mr. Speaker, Members

of the House of Delegates : The Reference Committee
on Reports of Special Committees wish to make the
following report.

IX-5. RE: COMMITTEE ON NURSES TRAIN-
ING SCHOOLS (VIII-1)

“We recommend that the Committee report be accepted and
concurred in, but that the committee be instructed to find some
solution for the present shortage of nursing help during this
emergency. It is suggested that the committee approach the
Legislative Committee of the State Society and through them
contact the Governor with the view in mind of bringing more
drastically to the State Board of Registration for Nurses the
marked harm being done by the present shortage, as well as
their lack of any definite policy for its immediate alleviation.”

Geo. H. Southwick, M.D., moved its adoption.

The motion was regularly seconded, put to a vote
and carried.

IX-5. PRELICENSURE MEDICAL EDUCATION
COMMITTEE (VIII-3)

Geo. H. Southwick, M.D. : Report of Representa-

tives to the Conference Committee on Prelicensure Med-

911

PROCEEDINGS HOUSE OF DELEGATES— 1941

ical Education. As you know, this committee is the
collaborating committee between the University of Mich-
igan, Wa3me University, and representatives of the hos-
pital association, and it was their intent and effort to
try to develop some agreeable plan for fifth year edu-
cation in the unaffiliated hospitals, by that I mean un-
affiliated with teaching institutions ;

“We recommend that this report be accepted, and that the
studies of this difficult problem be continued.”

Geo. H. Southwick, M.D., moved its adoption.

The motion was regularly seconded, put to a vote
and carried.

IX-5. RADIO COMMITTEE (VIII-4)

Report of Radio Committee : We approve the report

of the Radio Committee, and suggest that this type of
work be continued. We wish to thank the members of
this committee as well as the speakers for their services
to the profession and to the public.

Geo. H. Southwick, M.D., moved its adoption.

The motion was regularly seconded, put to a vote and
carried.

IX-5. ADVISORY COMMITTEE TO WOMAN’S
AUXILIARY (VIII-5)

“We recommend that this report be accepted and that the
future committee cooperate with the Auxiliary in the excellent
work they are doing.”

Geo. H. Southwick, M.D., moved its adoption.

The motion was regularly seconded, put to a vote and
carried.

IX-5. SCIENTIFIC WORK COMMITTEE
(VIII-6)

“The Reference Committee on Special Committees takes cog-
nizance of the Scientific Work Committee as reflected in the
program.

“The excellent array of talent should be greatly appreciated by
every member attending the general meetings, as well as the
Section Meetings on Friday.

“The eleven Discussion Conferences arranged for should be
extremely helpful. Cognizance should also be taken of the blank
slips in the Program upon which questions to guest essayists
may be written.

“Your Committee particularly commends the reestablishment of
scientific exhibits and believes this to be one of the most in-
structive features of the program.”

Geo. H. Southwick, M.D., moved its adoption.

The motion was regularly seconded, put to a vote
and carried.

IX-5. MEDICAL PREPAREDNESS COM-
MITTEE (VIII-2)

“We reviewed the report of the Committee on Medical Pre-
paredness and appreciate the amount of work in preparing and
clarifying the questionnaires.

“In view of the knowledge this Committee has obtained, we
recommend that this Committee be continued for the duration
of the present emergency.”

Geo. H. Southwick, M.D., moved its adoption.

The motion was regularly seconded, put to a vote and
carried.

Geo. H. Southwick, M.D. : I move the adoption of

the report of the Reference Committee as a whole.

The motion was regularly seconded, put to a vote
and carried.

IX-6. ON AMENDMENT TO CONSTITUTION
AND BY-LAWS

IX-6(a). UNFINISHED BUSINESS, FROM 1940
(VI-16)

The Speaker: The next order of business will be

the report of the Reference Committee on Amendments
to the Constitution and By-Laws, with the unfinished
business from the 19'40 House of Delegates.

E. W. Foss, M.D. : Mr. Speaker and Members of

the House of Delegates : I had the biggest shock of

by life. At our committee meeting this noon I found
the Speaker had made a mistake in putting me in as
Chairman. I found a member of our committee who
had been sleeping, eating and digesting the Constitu-
tion and By-Laws for the last three months. So I am
asking him to take over my job. Dr. Hess.

C. L. Hess, M.D. (Bay-Arenac-Iosco) : At Dr. Foss’
request, I have agreed to make the report of the Ref-
erence Committee on Amendments to the Constitution
and By-Laws.

The first has to do with the report on page 19 of
the Handbook concerning those resolutions that were
presented last year and come up this year for amend-
ment to the Constitution.

IX-6(a). PROPOSED CONSTITUTIONAL
AMENDMENT, ARTICLE IV,
SECTION 3, REJECTED

Article IV, Section 3.

The officers of this Society and the members of The Council
shall be ex officio members of the House of Delegates, and,
with the exception of the Speaker of the House of Delegates,
shall be without power to vote in the House of Delegates.

1. Amend Article IV, Section 3 to read as follows:

“The officers of this Society, Past Presidents, and Members
of the Council shall be ex officio members of the House of Dele-
gates without power to vote.”

C. L. Hess, M.D. : You will notice that the power

of the Speaker of the House to vote has been left out.
For that reason the committee is unanimous in not
recommending this resolution. There has been another
resolution presented concerning the Past Presidents,
which will take care of that particular phase. So that
the committee does not recommend the adoption of this
resolution. I make that motion, Mr. Speaker.

The motion was regularly seconded.

The question was called for, put to a vote and car-
ried.

IX-6(a). PROPOSED CONSTITUTIONAL
AMENDMENT, ARTICLE IX, SEC-
TION 4, REJECTED

Article IX, Section 4.

The Secretary shall collect all annual dues and all monies
owing to the Society, depositing them in an approved de-
pository and disbursed by him upon order of the Council. The
Council shall cause an annual audit to be made of the funds
of the Society by certified public accountants, and require the
Treasurer and the Secretary to be bonded for an adequate
amount.

2. Amend Constitution, Article IX, Section 4, to read as
follows:

“The Secretary shall collect all annual dues and all monies
owing to the Society, depositing them in an approved depository
and disbursed by him upon order of the Council, or invested
by him in United States Government bonds with approval of the
Council.”

C. L. Hess, M.D. : You will notice here, again, that
no provision is made for the annual audit. For that
reason, the committee recommends that this proposed
amendment not be approved. I make that motion, Mr.
Speaker.

The motion was regularly seconded, put to a vote and
carried.

IX-6(a). PROPOSED CONSTITUTIONAL
AMENDMENT, ARTICLE XII,
SECTION 1, ADOPTED

Article XII, Section 1.

The House of Delegates may amend any article of this con-
stitution by a two-thirds vote of the Delegates present at any
annual session, provided that such amendment shall have been
presented in open meeting at the previous annual session, and
that it shall have been published at least once during the year
in the Journal of the Society, or sent officially to each com-
ponent society at least two months before the meeting at which
final action is to be taken.

3. Amend Article XII, Section 1 to read as follows:

“The House of Delegates may amend any article of this con-

JOUR. M.S.M.S.

912

PROCEEDINGS HOUSE OF DELEGATES— 1941

stitution by a two-thirds vote of the Delegates seated at any
animal session, provided that such amendment shall have been
presented in open meeting at the previous annual session, and
that it shall have been published at least once during the year
in the Journal of the Society, or sent officially to each com-
ponent society at least two months before the meeting at which
final action is to be taken.”

C. L. Hess, M.D. : The question comes up here as

to the definition between “present” and “seated.” You
all recall the arguments that came up last year on that
particular question.

The committee recommends the adoption of this res-
olution. I make that motion.

The motion was regularly seconded, put to a vote
and carried.

IX-6(a). PROPOSED CONSTITUTIONAL
AMENDMENT, NEW ARTICLE
XII, AND RENUMBERING OLD
ARTICLE XII TO “ARTICLE
XIII”— ADOPTED

C. L. Hess, M.D. read the new article to be known
as Article XII.

4. Amend Constitution by adding a new article to be known
as Article XII:

“Section 1. — A session shall mean all meetings at any one call.

“Section 2. — A meeting shall mean each separate convention
at any one session.”

C. L. Hess, ^I.D. : I think the meaning of that is

clear to all. The committee recommends the adoption
of this resolution. There is another point. Amend
the Constitution by renumbering old Article XII to
Article XHI, to make the numbering consecutive. The
committee recommends the adoption of this amendment.

The motion was regularly seconded, put to a vote
and carried.

IX-6(a). PROPOSED BY-LAWS AMENDMENT,
CHAPTER 10, SECTION 1, ADOPTED

C. L. Hess, M.D. : The next has to do with a By-

Law that was presented at the last meeting.

T. K. Grubb3{, M.D. : !Mr. Speaker, I move that this

By-Law be taken from the table. It was laid on the
table last year.

The motion was regularly seconded, put to a vote
and carried.

Chapter 10 — Amendments

Section 1. These By-Laws may be amended by a majority vote
of the delegates present, after the proposed amendment is laid
on the table for one session. These By-Laws become effective
immediately upon adoption.

6. Amend By-Laws, Chapter 10, Section 1, to read as follows:

“These By-Laws may be amended by a majority vote of the
delegates present, after the proposed amendment is laid on the
table for one meeting. These By-Laws become effective imme-
diately upon adoption.”

C. L. Hess, M.D., moved its adoption.

The motion was regularly seconded, put to a vote
and carried.

C. L. Hess, M.D. ; There are several proposed amend-
ments to the Constitution which must lay over for one
year.

The Speaker: They go to the 1942 committee.

IX-6(b). RE: BY-LAWS CHANGES PROPOSED
BY 1941 HOUSE OF DELEGATES
IX-6(b). PROPOSED BY-LAWS AMENDMENT,

CHAPTER 3, SECTION 2 (VI-8)— ADOPTED
(See page 903)

C. L. Hess, M.D. moved its adoption.

The motion was regularly seconded, put to a vote
and carried.

IX-6(b). PROPOSED BY-LAWS AMENDMENT,
CHAPTER 3, SECTION 7-d (VI-13)—

ADOPTED (See page 904)

C. L. Hess, M.D. moved its adoption.

The motion was regularly seconded, put to a vote
and carried.

IX-6(b). PROPOSED BY-LAWS AMENDMENT,
CHAPTER 5, SECTION 1 (VI-10)—
ADOPTED (See page 904)

C. L. Hess, M.D. : The next refers to Chapter 5,

Section 1 of the Bj^-Laws, that has to do with the an-
nual meeting, where the By-Laws conflicts with the
Constitution. One sets the meeting for September
and the other in January-. This amendment recom-
mends the deletion of the sentence specifying the an-
nual meeting in the By-Laws, and leaves that specifica-
tion in the Constitution still active.

C. L. Hess, !M.D. moved its adoption.

The motion was regularly seconded, put to a vote
and carried.

IX-6(b). PROPOSED BY-LAWS AMENDMENT,
CHAPTER 5, SECTION 1 (VI-12)—
ADOPTED (See page 904)

C. L. Hess, M.D. : Chapter 5, Section 1 of the By-

Laws refers to elections in the Council. You heard
President Urmston’s discussion regarding this pro-
posed change, and this covers his discussion.

C. L. Hess, M.D. : The argument is that, since this

sentence of the proposed amendment provides for an
Executive Committee, it is not necessarj^ to have the
fifth sentence, which specifies the formation of an ex-
ecutive body, since it would be a duplication.

]^Ir. Speaker, the committee recommends the adoption
of this resolution.

The motion was regularly seconded, put to a vote
and carried.

C. L. Hess, M.D. read the resolution proposing amend-
ments contingent upon adoption of new Article XII.

C. L. Hess, M.D. : I -wish to abbreviate this report.

In these three By-Laws which are affected by this
change in the Constitution, the committee recommends
that this By-Law be held over for one more meeting,
because other By-Laws have been presented at this
particular meeting which will make a desirable correc-
tion. That has to do with the third Bj’-Law :

“These By-Laws may be amended by a majority vote of the
delegates present, after the proposed amendment is laid on the
table for one meeting.”

The question, again, of the word “seated” comes up.
It seemed desirable to change the word “present” to
“seated,” which would require a majority of delegates.
Amendments, as I say, have been presented by Dr.
Foss this afternoon, which will take up this amend-
ment and the additional amendment, to make these cor-
rections.

The committee recommends that this resolution be
laid over for one more meeting.

The motion was regularly seconded, put to a vote
and carried.

C. L. Hess, M.D. : Mr. Speaker, I move the adop-

tion of the report as a whole.

The motion was regularh' seconded, put to a vote
and carried.

The Speaker: The next order of business will be

the report of the Reference Committee on Resolutions,
Dr. Cooksey.

IX-4. REFERENCE COMMITTEE ON
RESOLUTIONS RE: SPECIAL
MEMBERSHIPS (V-2)

W. B. Cooksey, M.D. : !Mr. Speaker, Members of the
House of Delegates : The Reference Committee on

November, 1941

913

PROCEEDINGS HOUSE OF DELEGATES— 1941

1

Resolutions wish to recommend, after due study and
clearing of all records, for Emeritus Membership, re-
quested by the various county societies, the following ;

For Emeritus Membership :

1. Charles D. Aaron, M.D., Detroit — Wayne County

2. Angus L. Cowan, M.D., Detroit — Wayne County

3. Gilbert S. Field, M.D., Detroit — Wayne County

4. George E. Frothingham, M.D., Detroit — Wayne County

5. Fred J. Graham, M.D., Alma — Gratiot-Isabella-Clare County

6. Abraham Leenhouts, M.D., Holland — Ottawa County

7. Wm. C. Martin, M.D., Detroit — Wayne County

8. Irwin H. Neff, M.D., Detroit — Wayne County

9. Walter R. Parker, M.D., Detroit — Wayne County

10. G. L. Renaud, M.D., Detroit — Wa5me County

11. M. D. Ryan, M.D., Saginaw — Saginaw County

12. Joseph E. G. Waddington, M.D., Detroit — Wayne County

W. B. Cooksey, M.D. : We wish to recommend that

these men be given Emeritus Membership.

The motion was regularly seconded, put to a vote
and carried.

For Retired Membership:

1. Charles W. Ash, M.D., Bay City — Bay County

2. H. S. Bartholomew, M.D., Lansing — Ingham County

3. H. J. Hammond, M.D., Detroit — Wayne County

4. E. G. McConnell, M.D., Lansing — Ingham County

5. J. H. O’Dell, M.D., Three Rivers — St. Joseph County

6. C. H. O’Neil, M.D., Flint — Genesee County

7. C. V. Russell, M.D., Lansing — Ingham County

8. C. M. Swantek, M.D., Bay City — Bay County

W. B. Cooksey, M.D. ; We recommend that they be
given retired membership.

The motion was regularly seconded, put to a vote and
carried.

IX-4. RE: SECTION ON GENERAL PRACTICE
(V-6)

W. B. Cooksey, M.D. : The following resolutions

were presented for our consideration ;

W. B. Cooksey, M.D., read the resolution introduced
by Henry A. Luce, M.D., concerning a Section of Gen-
eral Practice (See page 905).

W. B. Cooksey, M.D. : We wish to call attention to

the fact that if this resolution, which is proposed, to
create a Section of General Practice, is adopted, it
does not give, in the Michigan State Medical Society,
any representation having to do with administration and
jurisprudence of the Society. It only creates a sci-
entific section, with a chairman and a secretary.

May I read Article 6, Section 4 of our Constitution
and By-Laws, which states ;

“New sections may be created or existing sections discontinued
by the House of Delegates. The Scientilc Assembly and its com-
ponent sections shall be conducted in accordance with the pro-
visions of the Constitution and By-Laws.’’

After due consideration, your committee recommends
that this resolution, creating a Section of General Prac-
tice, be approved, that we recommend a General Prac-
tice Section be given a trial period.

The motion was regularly seconded, put to a vote
and carried.

IX-4. RE: PROFESSIONAL LIAISON
COMMITTEE (V-5)

W. B. Cooksey, M.D. : The second resolution con-

cerns Dr. Allan McDonald’s resolution which has to
do with the creation of a committee of dentists, phar-
macists and doctors, having to do with working to-
ward common causes (See page 904).

The committee recommends that this resolution be
adopted.

The motion was regularly seconded.

The Speaker: All in favor of this motion say

“aye” ; opposed the same. The motion is carried.

IX-4. RE: ELECTION OF DELEGATES
TO A.M.A. (V-4) (See page 904)

W. B. Cooksey, M.D. : This is to clarify and prevent
an occurrence such as happened at the A.M.A. in
Cleveland, in which there was quite a disturbance over
an Oklahoma delegate. W’e recommend this be adopted.

The motion was regularly seconded, put to a vote
and carried.

IX-4. RE: NATIONAL PHYSICIANS
COMMITTEE (V-7)

W. B. Cooksey, M.D. briefed the resolution approv-
ing program of National Physicians’ Committee (See
page 905).

W. B. Cooksey, ]\I.D. : This is simpR- a matter of

our Secretary writing a letter or letters, and there
are no legal strings attached so that the A.M.A. or
either of these two component societies will be liable.

Your committee, after due consideration, recommends
this resolution be adopted.

The motion was regularly seconded, put to a vote and
carried.

IX-4. RE: APPRECIATION TO MICHIGAN
LEGISLATURE AND GOVERNOR (V-1)

W. B. Cooksey, M.D. : The last resolution concerns

expressing our appreciation to the members and officers
of the Michigan Legislature and His Excellency the
Governor. (See page 901.) We recommend that the
resolution expressing appreciation to the Legislature
and to His Excellency the Governor be adopted.

The motion was regularly seconded, put to a vote
and carried.

W. B. Cooksey, M.D. : I move that the total recom-
mendations of the committee be adopted.

The motion was regularly seconded, put to a vote
and carried.

VI-17. BY-LAWS AMENDMENT RE: SPECIAL
MEMBERSHIP APPLICATIONS (PROPOSED
CHANGE IN BY-LAWS, CHAPTER 7,
SECTION 1)

L. J. Johnson, M.D. : After sitting through many

sessions of this House, and hearing the presentations
of resolutions for the transfer of active members to
some of the other categories, such as Honorary Mem-
bers and Retired Members, then being informed by
our good Secretary that, although he had written let-
ters several days and several weeks ago to the county
secretaries, asking that these resolutions be sent in early,
several of them arrived after this meeting convened,
and considerable expense was incurred in getting in
touch with the Lansing office and establishing the cred-
its of these men, therefore, we are presenting this res-
olution to amend the By-Laws, to be known as Sec-
tion 7 of Chapter 1. It is really an addition.

Whereas, before active members of the Michigan State Med-
ical Society may be transferred to the Roster of either Hon-
orary Members, or Retired Members, or Members Emeritus,
proper investigation of their qualifications must be made for
such transfer as provided in Article 3 of the Constitution, Sec-
tions 4, 6, and 7, then

Be it resolved, that the County societies send resolutions
for such transfers to the Secretary of the State Society at least
thirty days before the annual meeting of the Society.

Be it further resolved that the Secretary of the State So-
ciety present a resolution essentially combining these resolutions
in a compact form to the House of Delegates at the regular
annual meeting of the Society.

The Speaker: This resolution will be referred to
the Reference Committee on Amendments to the Con-
stitution and By-Laws.

Gentlemen, this concludes our business for this after-
noon.

The meeting recessed at six o’clock.

914

Jour. iM.S.M.S.

PROCEEDINGS HOUSE OF DELEGATES— 1941

Tuesday Evening Meeting

September 16, 1941

The third meeting convened at eight-twenty o’clock,
The Speaker, O. D. Stryker, M.D., presiding.

The Speaker : The third meeting of the House of

Delegates is now called to order.

We will have the supplementary report of the Com-
mittee on Credentials.

Luther W. Day, M.D. (Hillsdale) : Mr. Speakej*,

there are now seated in the House of Delegates 56
members. This constitutes a quorum, and there is
no majority from any one particular count>\ Con-
sequently, the House is legally constituted.

The Speaker; If there is no objection from the
House, the report of the Committee on Credentials will
be considered the roll call.

The next order of business will be supplementary re-
ports from reference committees.

Is there a supplementarj- report from the Reference
Committee on Officers’ Reports?

On Reports of the Council?

On Reports of Standing Committees?

On Reports of Special Committees?

IX-6(b). ON AMENDMENTS TO CONSTITU-
TION AND BY-LAWS

IX-6(b). PROPOSED BY-LAWS AMENDMENT,
CHAPTER 10, SECTION 1 (VI-15)
ADOPTED

E. O. Foss, M.D. : We have several amendments to

consider. The first is Chapter 10, Section 1 of the
By-Laws (See page 909).

We recommend the adoption of this resolution.

The motion was regularly seconded.

The Seapker : iMoved and seconded that this reso-

lution be adopted as read. Are there any remarks? If
not, all in favor say “aye” ; opposed the same sign. The
motion is carried.

IX-6(b). PROPOSED BY-LAWS AMENDMENT,
CHAPTER 4, SECTION 4 (VI-14)—
ADOPTED (See page 909)

E. O. Foss, M.D. : The next one is Chapter 4, Sec-
tion 4 of the By-laws.

We recommend the adoption of this resolution.

The Speaker: Is there support?

The motion was regularly seconded.

The Spe.a.ker; Moved and supported that this res-
olution be adopted as read. Are there any remarks?

C. L. Hess, M.D. (Bay-Arenac-Iosco) : Mr. Speak-

er, regarding this particular sentence being deleted,
as you recall this afternoon there was formed an ex-
ecutive committee composed of the chairmen of various
committees of The Council and certain officers, which
was passed. Now there is a conflict with that particular
amendment regarding the Secretary’ imder “Duties of
the Officers,” Section 4, Chapter 4, which says that the
Secretary “shall be an ex officio member,” and so forth,
without a vote. By deleting this, the other amendment
this afternoon takes care of the problem.

The Speaker: All in favor of the motion say “aye”;
opposed the same. The motion is carried.

IX-6(b). PROPOSED BY-LAWS AMENDMENT,
CHAPTER 3, SECTION 1 (VI-6)—
ADOPTED (See page 903)

IX-6(b). PROPOSED BY-LAWS AMENDMENT,
CHAPTER 3, SECTION 7-L (VI-7)—
ADOPTED (See page 903)

All we have done here is change the word “Sessions”
to “Meetings.”

I move the adoption of these two amendments.

The motion was regularly seconded.

November, 1941

The Speaker: It has been moved and supported.

All in favor say “aye” ; opposed the same sign. The
motion is carried.

IX-6(b). PROPOSED BY-LAWS AMENDMENT,
CHAPTER 1, NEW SECTION 7 (VI-1)—
ADOPTED

E. O. Foss, M.D. : The proposed amendment to

Chapter 1 is as follows ; Amend Chapter 1 by adding
a section to be known as Section 7. (See page 902.)

E. O. Foss, M.D. ; I move the adoption of this res-
olution.

The motion was regularly seconded.

The Speaker; It has been moved and supported.
All in favor say “aye” ; opposed the same. The motion
is carried.

IX-6(b). PROPOSED BY-LAWS AMENDMENT,
CHAPTER 7, SECTION 1 (VI-17)—
REFERRED TO 1942 SESSION

E. O. Foss, M.D., read the resolution concerning spe-
cial membership applications (for honorary, retired, or
members emeritus) (See Page 914).

E. O. Foss, M.D. : The committee is not prepared

to act on this, and we recommend that this be held
over until the next annual session. I so move.

The motion was regularly seconded.

The Speaker: Moved and supported that this be

held over to the next annual session. All in favor say
“aye” ; opposed the same. The motion is carried.

E. O. Foss, M.D. : I move the adoption of the Ref-

erence Committee Report as a whole.

The motion was regularl}' seconded.

The Speaker: Moved and supported that the Ref-

erence Committee Report be adopted as a whole. All
in favor say “aj-e” ; opposed the same. The motion is
carried.

X. Elections

X-l. COUNCILOR OF FIRST DISTRICT

Our next order of business will be elections. Our
first election will be for Councilor of the First Dis-
trict, C. E. Umphrey, M.D., incumbent.

E. R. WiTWER, M.D. (Wa\Tie) : During the past few

years Wayne County has been very fortunate in having
on The Council of the State Society a gentleman of
distinction, refinement, culture and ambition, and it is
the desire of the Wa>Tie delegation that Clarence E.
Umphre}’, M.D., be continued as a member of The
Council representing the First District of Wa3Tie
County, and it is m3' pleasure to place his name before
this assembU’ for that distinguished office.

The motion was regularl3’ seconded.

The Speaker: Nomination has been moved and sup-
ported. Are there au3' further nominations?

T. K. Gruber, M.D. (Wa3me) : I move that nom-

inations be closed.

The motion was regular^" seconded.

The Speaker; Moved and supported that nomina-
tions be closed. All in favor sa3' “a3’e” ; opposed the
same. The motion is carried.

X-2. COUNCILOR OF FOURTH DISTRICT

Fourth District, R. J. Hubbell, M.D., Kalamazoo, in-
cumbent.

I. W. Brown, M.D. (Kalamazoo) : R. J. Hubbell,

M.D., of Kalamazoo, has served us during the last two
3'ears ver3' efficienth', and I think the delegates from
the other counties, as well as Kalamazoo, that comprise
the Fourth Councilor District, join me in proposing
the name of Dr. Hubbell to succeed himself for an-

915

PROCEEDINGS HOUSE OF DELEGATES— 1941

other term as Councilor for our District, and I so
nominate R. J. Hubbell, M.D., of Kalamazoo.

The Speaker: Are there any further nominations?

C. L. Hess, M.D. (Bay-Arenac-Iosco) : I move that

nominations be closed.

The motion was regularly seconded.

The Speaker: All in favor say “aye”; opposed the

same.

All in favor of the election of Dr. Hubbell say “aye” ;
opposed the same. Dr. Hubbell is elected.

X-3. COUNCILOR OF FIFTH DISTRICT

Next will be the Fifth District, Vernor M. Moore,
AI.D., Grand Rapids, incumbent.

Carl F. Snapp, M.D. (Kent) : Members of the

House of Delegates : The Fifth District has been ex-

ceedingly fortunate for several years in having on The
Council a tireless worker. He has been a valued mem-
ber of The Council for several years now, a member
of the Executive Committee where he has been chair-
man of the Finance Committee, and as such has been
termed by several as the watchdog of the treasury
of our Society. He has been vitally interested in every
phase of organized medicine. He has had every prac-
titioner in his District very much at heart in all he
has done.

I take great pleasure in renominating Vernor M.
Moore, M.D. as Councilor of the Fifth District to suc-
ceed himself.

The motion was regularly seconded.

The Speaker: Dr. Moore has been nominated and

supported. Any further nominations?

A. E. Stickley, M.D. (Ottawa) : I move that nom-
inations be closed.

The motion was regularly seconded.

The Speaker: Moved and supported that nomina-

tions be closed. All in favor of Dr. Moore as Coun-
cilor of the Fifth District say “aye” ; opposed the same.
Dr. Moore is elected.

X-4. COUNCILOR OF SIXTH DISTRICT

Next will come the Sixth District, Ray S. Morrish,
M.D.. of Flint, incumbent.

I. W. Greene, M.D. (Shiawassee) : It is incumbent

upon me to dwell on the good Councilors we have had
for our District in the past, but I will say we have
been well represented within the last year and I would
like to place in nomination the name of Raj^ Mor-
rish, M.D.

The Speaker: Dr. Morrish has been nominated.

Any further nominations?

The nomination was regularly seconded.

The Speaker: And seconded. If there are no fur-

ther nominations, all in favor of Dr. Morrish will say
“aye” ; opposed the same. Dr. Morrish is elected.

X-5. DELEGATES TO A.M.A.

Our next order of business is the election of a dele-
gate to the American IMedical Association, L. G. Chris-
tian, M.D., Lansing, incumbent.

T. I. Bauer, M.D. (Ingham) : I should like to place
again for nomination the name of L. G. Christian, ^LD.
We in Ingham County are very proud of the work
he has done, both for us and for the State Medical
Society, and also on the Welfare Commission and as
delegate to the A.M.A. We believe he understands our
problems and we would like to see him returned, so I
am happy to nominate L. G. Christian, M.D.

The nomination was regularly seconded.

The Speaker: The nomination of Dr. Christian has
been moved and supported. Are there any further
nominations? If not, all in favor of Dr. Christian say
“aye” ; opposed the same. Dr. Christian is elected.

We are now at the stage where the Speaker will
select the name of a martyr who will resign, on promise

of being reelected, so as to straighten up this mess.
Dr. Reeder is the sheep led to the slaughter. Dr.
Reeder, you have the floor. It is your duty to resign,
upon the promise of being rejected.

Frank E. Reeder, M.D. (Genesee) : Mr. Speaker,
being a young man in this House of Delegates and
being the so-called baby or the junior delegate to the
American Medical Association, I don’t think this has
been a game of chance here at all. I think it is right
fitting and proper that I should resign. It requires
a two-fisted guy to be Sergeant-at-Arms in the House
of Delegates to the A.M.A., and last year when I
polled the House with a ten-gallon hat and a .32 hanging
down for a watch charm, Michigan really made them
sit up and take notice.

However, I am very happy and it should be proper
to favor my seniors. Therefore, Mr. Speaker, I resign
as delegate to the A.M.A.

The Speaker: Thank you.

There is a motion that the resignation of Dr. Reeder
be accepted.

L. G. CHRISTI.A.N, M.D. (Ingham) : I want to say

it is with a great deal of regret that he had to resign
and that he had to be reelected.

Frank E. Reeder, M.D. (Genesee) : Mr. Speaker, I
think if the delegates looked closely they saw no tears.

The Speaker: All in favor of the resignation of

Dr. Reeder say “zyt” ; opposed the same. His resig-
nation is accepted.

A. E. Catherwood, M.D. (Wayne) : Now that we
have gotten rid of Dr. Reeder, I think we should make
it permanent, but I should like to nominate him again
to succeed himself.

The Speaker: Dr. Reeder has been nominated.

The nomination was regularly seconded.

The Speaker: Are there any further nominations?

Motion was regularly made and seconded that nomi-
nations be closed.

The Speaker: Moved and supported that nomina-
tions be closed. All in favor of Dr. Reeder say “aye” ;
opposed the same. Dr. Reeder is elected.

X-6. ALTERNATE DELEGATES TO A.M.A.

Now we have the election of alternate delegates to
the American Medical Association. There are two
incumbents, George J. Curry, !M.D., and Ralph H. Pino,
M.D. Are there any nominations?

George J. Curry, M.D. (Genesee) : I should like to
place in nomination the name of I. W. Greene, M.D.,
of Owosso, for alternate.

The Speaker: Dr. Greene has been nominated as
alternate delegate. Are there an}^ further nominations?

S. W. Insley, M.D. (Wa>Tie) : I should like to
place in nomination the name of a man who was
incumbent before and who, I believe, richly deserves
the honor — Ralph H. Pino, M.D.

The Speaker : Are there further nominations ?

C. S. Ratigan, M.D. (V’a3'ne) : I move that nomi-
nations be closed.

C. L. Hess, M.D. (Bay-Arenac-Iosco) : I second the
motion.

The Speaker: We will have to vote by ballot to
determine seniority. Will the Tellers who seiA'ed this
afternoon again come forward ?

L. J. Hirschman, M.D. (Wa3me) : Point of infor-
mation. Didn’t I understand from the revision of the
Constitution and By-Laws that seniority was covered
by the fact of whether a man has served before or
not? If so. Dr. Pino has already served and is the
senior.

C. L. Hess, M.D. : That is right.

The Speaker: That answers your question.

C. S. Ratigan, M.D. : Isn’t that laid on the table
until next year?

William S. Reveno, M.D. (Wa\Tie) : Seniority is
determined, according to the new resolution, first by

Tour. M.S.M.S.

916

PROCEEDINGS HOUSE OF DELEGATES— 1941

the length of time that the alternate delegate has ser\-ed,
and secondly b>- the number of votes polled in being
elected. There are two factors that determine seniority.
A man whose term has expired starts in again. The
one holding office now assumes seniorit3% and the man
who holds the highest number at this time takes his
place in line.

T HE Speaker : We will have an election.

R L. Xot'Y, M.D. (^^'a^Tle) : I should like io make
a motion that in view of the seniority- of Dr. Pino
on previous occasions, election be dispensed with and
that he be delegated as senior. I move to suspend the
rules.

The motion was regularh' seconded.

The Sphaker: Moved and supported that the rules
be suspended and that, in view of the seniority' of
Dr. Pino, he be declared the senior alternate. All in
favor say “aj^e” ; opposed the same. The motion is
carried.

X-7. PRESIDENT-ELECT

The next order of business is the nomination of a
President-Elect.

JoHX A. Wessixger, M.D. (Washtenaw) ; Mr.
Speaker and ^Members of the House of Delegates. I
presume I am the 3'oungest member in the House.
I have sat with you continuoush' for tnent\"-five years.
Rather reticent in spirit, I have had little to say, but
tonight I beg the privilege of using not more than
five minutes to give j'ou my message.

The gentleman whom I have in mind I have known
for man\- 5’ears. I have nothing but favorable impres-
sions of him. ^ly contacts have been numerous. I
know and >'OU know that he has done j'eoman work
for this organization for manj- j-ears.

On two different occasions he has stood back when
we urged him to come forward, and now we feel it is
no longer his privilege to stand back. This gentleman
has fine administrative abilities. He has a fine and
splendid executive acumen, and nothing can afford me
greater pleasure, and I feel it a high honor to be
permitted to stand here before you gentlemen and
place in nomination Howard H. Cummings, M.D., for
President-Elect.

G. C. Pexberthy, M.D. (Waj-ne) : Mr. Speaker and
Members of the House of Delegates : Howard Cum-
mings and I were classmates. I have known Howard
since 1906. As an officer of the State Society- he has
contributed materially to the welfare not only of the
Societj' but of the people of Michigan, and it is mj*
pleasure to second the nomination of Howard Cum-
mings as President-Elect

The Spe-\ker : Are there an}- further nominations?

E. R. WiTWER, M.D. (M'a\-ne) : I move that nomi-
nations be closed.

The motion was regularly seconded.

The Speaker : It is moved and supported that nomi-
nations be closed. All in favor sa}’ “aye” ; opposed the
same.

All in favor of Howard Cummings as President-Elect
sa\* “a3'e” ; opposed the same. Dr. Cummings is unani-
moush- elected. Mill \'ou come forward and take a
bow?

The audience arose and applauded.

Presh)ext-Elect Cummixgs : Mr. Speaker and Gen-
tlemen ; I feel deeph’ the honor 50U have bestowed
upon me. I can think of man}' men in 3-our organiza-
tion who have ser\'ed longer and better than I have,
but I do feel this is a wonderful time for an}- doctor
in the Michigan State Medical Societ}' to render ser\--
ice, because for }ears doctors have been individualists.
They have met their problems of life and death alone,
and the}' have solved most of them alone.

In the last ten years, in this organization we have
seen cooperation among doctors as never before, and

XOVXMBER. 1941

ever}- doctor belonging to this organization owes it to
his feUow physicians to render some servdce for organ-
ized medicine, for the doctors of our state, and, most
of all, for the people of our state.

Knowing that you men will cooperate with Henry
Carstens this year, and with me as I come on the
year following, it is going to be a pleasure to work
with you. Thank you.

X-8. COUNCILOR OF FOURTEENTH
DISTRICT

The Speaker: There now exists a vacancy of Cotm-
cilor of the Fourteenth District to succeed Dr. Cum-
mings. Nominations are now in order for Councilor
for the Fourteenth District.

E. R. Mitvs-er, M.D. (Wa}-ne) : I have watched the
development of a lot of our younger men in Ann Arbor
for quite some time.

The Speaker: This nomination must be from a dele-
gate of his Councilor District.

L. E. Kxoll, AI.D. (Washtenaw) : I am truly a

baby in the House of Delegates. I will make my
speech short. I will nominate one of my confreres
from Ann Arbor, L J. Johnson, M.D.

The Speaker : L. I. Johnson, M.D., of Ann Arbor,
has been nominated as Coimcilor for the Fourteenth
District.

The nomination was regularly seconded.

The Speaker: His nomination has been supported.
Are there any further nominations?

John A. Wessixger, AI.D. (Washtenaw) : I move
that nominations be closed.

The motion was regularly seconded.

The Speaker : Moved and supported that nomina-
tions be closed. All in favor of Dr. Johnson will say
“aye” ; opposed the same. The motion is carried, and
Dr. Johnson is imanimously elected.

X-9. SPEAKER OF HOUSE OF DELEGATES

The next order of business is election of the Speaker
of the House of Delegates.

T. K. Gruber, M.D. (Wa}-ne) : Mr. Speaker, the
position of Speaker of the House of Delegates, as well
as member of The Council of the Alichigan State Medi-
cal Societ}', entails a great deal of time and effort on
the part of the Speaker, and entails a lot of time away
from office.

Dr. O'AIeara does not feel he would be in position
to devote the time necessaiy to the position of Speaker
of the House of Delegates, and, therefore, I wish to
place in nomination the name of a man from Wa}Tie
Coimt}- who is one of the up and coming yoimg men
of the Wa}'ne Cotmt}- Aledical Society. He has de-
voted a great deal of time and effort to the problems
of organized medicine. He realizes it will take a
great deal of his time and effort, and he is perfectly
willing to make the effort to devote this time, and
I am sure he will be a credit to the position.

I take pleasure in being asked by the W'a}'ne delega-
tion to place P. L. Ledwidge, AI.D., in nomination for
the position of Speaker of the House.

R. M. McKeax, M.D. (Wa}-ne) : It is my priHlege
and pleasure to support this young man Dr. Gruber
has so eloquently nominated for this particular office.

The Speaker: Are there any further nominations?

Hexry a. Luce, M.D. (Wa}-ne) : When one internist
supports another, I think it is time to close the nomi-
nations.

The Speaker: Moved and supported that nomina-
tions be closed. All in favor of Dr. Ledwidge as
Speaker of the House of Delegates say “aye” ; opposed
the same. Dr. Ledwidge is imanimously elected Speaker
of the House of Delegates.

917

PROCEEDINGS HOUSE OF DELEGATES— 1941

X-10. VICE SPEAKER OF HOUSE
OF DELEGATES

The next order of business will be the election of a
Vice Speaker of the House of Delegates. Nomina-
tions are now in order.

L. J. Hirschman, M.D. (Wayne) ; Mr. Speaker, I
am going to place the name of a man in nomination
for Vice Speaker of the House, and the most sur-
prised person in this assembly will be the man whose
name I am going to present.

He is one of the younger men, as you will note, a
man who has had a great deal of legislative experience,
knows something about parliamentary law, and I believe
would represent the general practitioner in the small
community as well as in the legislature of our state.

I place in nomination the name of S. L. Loupee, M.D.,
of Dowagiac.

The Speaker: Dr. Loupee, of Dowagiac, has been
nominated.

E. O. Foss, M.D. (Muskegon) : I would like to place
in nomination the name of George Southwick, M.D.

The Speaker ; Dr. Southwick has been nominated.
Are there any further nominations?

S. L. Loupee, M.D. (Cass) : It certainly is a sur-
prise to me to have somebody present my name here
at this time in connection with an office in this group.
I would appreciate the opportunity of doing what I
possibly could do in the interests of this organization,
because my heart and life are wrapped up in the prog-
ress of organized medicine, but I already have an obli-
gation that takes me away from my work, that divides
my attention, and that is a real obligation in so far
as I am able to perform it. People down our way
elected me as a member of the Alichigan House of
Representatives and in that position I have served two
terms, and I doubt whether there are many men who
know just what it means. There are many people who
think it is just a fine opportunity to get aw^ay from
home and have a good time, and don’t realize what
sacrifice one offers when he undertakes an obligation
of that kind.

I have enjoyed my work in the Legislature, and I
want to do what I can in the interests of organized
medicine.

Thanking Dr. Hirschman for offering my name, I
withdraw in favor of the other nominee.

L. O. Geib, M.D. (Wayne) : I move that nomina-
tions be closed.

The motion was regularly seconded.

The Speaker: Moved and supported that nomina-
tions be closed. All in favor of Dr. Southwick say
“aye” ; opposed the same. Dr. Southwick is unanimously
elected Vice Speaker.

That concludes our business for the day.

XL New Business

XI-l. HONORARIUM TO RETIRING SPEAKER

Frank E. Reeder, M.D. : Mr. Speaker and Members
of the House: Two years ago, when Philip Riley, M.D.,
retired as Speaker, and six years ago when I retired
as Speaker, this House was very kind. The members
voted a little honorarium to Dr. Riley and likewise
to me.

I would like to offer a motion that this House of
Delegates vote a sum not to exceed $25 to present an
emblem of appreciation to our Speaker upon his retire-
ment. I feel he is entitled to it, and I so move.

The motion was supported by several.

The Speaker: Dr. Ledwidge, will you take the chair,
please?

P. L. Ledwidge, the Speaker-Elect, assumed the
chair.

The S pea ker- Elect : Gentlemen, I should like to say
in the beginning that to be elected to this office is a
high honor and a responsibility. I thank you sincerely
for the honor, and I accept the responsibility.

There is a motion before the House, Dr. Reeder’s
motion that this body appropriate an amount for a
proper emblem for our retiring Speaker. The motion
has been supported by several. Is there any discussion?

All in favor say “aye” ; opposed. The motion is car-
ried. The Secretary will carry out this order, Mr.
Speaker, and I want to congratulate you on the very
nice work you have done for two years.

The Speaker, O. D. Stryker, M.D., resumed the chair.

The Speaker: I wish to thank you very much. It
has indeed been a great pleasure — and I mean it — to
serve as your presiding officer for two j'ears. There
are headaches, but there is pleasure, too, and it gives
anyone a big inward glow to work with such a fine
group of fellows when he becomes a member of The
Council and the Executive Committee, and also Speaker
of the House of Delegates. Thank you again.

XI-2. PLACE AND DATE OF 1942 ANNUAL
MEETING

The Speaker: There is but one more question, and
that is the place and date of the 1942 annual meeting.
In the last couple of years this has been left to The
Council. It can be decided by either the House of
Delegates or The Council.

We have two invitations, one from Grand Rapids
and one from Detroit. Is it the pleasure of the House
to accept one of these invitations, or to leave the mat-
ter up to The Council?

T. K. Gruber, ]\LD. (Wayne) : Mr. Speaker, I move
that the invitations for the place of meeting be turned
over to The Council, and that they be requested to de-
cide on the place and date of the 1942 Convention to
the best advantage of the Society, the exhibitors, and
all concerned.

Carl F. Snapp, M.D. (Kent) : I support that mo-
tion.

The Speaker: Moved and supported that this mat-

ter be left to The Council and they decide which will
be to the best advantage of all concerned. All in favor
say “aye” ; opposed the same. The motion is carried.

G. C. Penberthy, M.D. (Wayne) : My attention has
just been invited to the illness of Dr. Dempster, and
I was given to understand he is about to be moved
to a hospital. Dr. Dempster was our Editor for many
years, a faithful servant to this Society, and I would
move that the Secretary telegraph Dr. Dempster our
sympathy, and try to build up the morale that is neces-
sary. We all have known Dr. Dempster many years,
and I think it only fitting that this House of Delegates,
before adjourning, give some expression of their ap-
preciation for the services rendered by Dr. Dempster.

The motion was regularly seconded and carried.

XII. Adjournment

We are now adjourned.

The meeting adjourned at nine-fifteen o’clock.

THE 77TH ANNUAL MEETING, MSMS
SEPTEMBER 22, 23, 24, 25, 1942
GRAND RAPIDS

918

Jour. M.S.M.S.

APPLES!"

is the Children's War Cry

And a healthy war cry, too . . . when children call for
apples! Read what one well known dietitian says
about the healthful qualities of apples:

with bland, non-irntating bu .

»App.es, scraped, cooked or

eigriretriedy for generations

tinal disorders, and at . j- -„»

extensively used in therapeutic diets.

Taken horn the Sixty-Ninth An-
nual Report oi ^Ziety

the State Horticultural Society
of Michigan for the year 1939.

, . . ro.-

wroS-n oi H..KS ■■

Apples furnish Vitamins,^ Minerals, Pectin, Non-
Irritating Bulk. Good for you . . . and good to eat.

MICHIGAN STATE APPLE COMMISSION

LANSING, MICHIGAN

/\/a^s€^ MICHIGAN

FOR JUICE . . . FLAVOR . . . HEALTH

Novemhek, 1941

Say you saw it in the Journal of the Michigan State Medical Society

919

X- YOU AND YOUR BUSINESS >^

INSTALMENT CREDIT REGULATIONS NOT
TO AFFECT LOANS FOR MEDICAL
AND HOSPITAL EXPENSES

Loans for medical, hospital, dental or funeral
expenses are exempt from the instalment credit
regulations, if the obligor could not reasonably
meet the requirements of the regulations.

The Federal Reserve Board, folowing out the
executive order of President Roosevelt giving the
Board authority to investigate, regulate and pro-
hibit transfers of credit, adopted on August 21,
1941, Regulation “W” which is the first step in
carrying out the purpose stated in the President’s
order. Regulation “W” fixes the maximum
spread on time payments for various instalment
purchases, at 18 months. This includes cash
loans of less than $1,000 as well as specific list
of 24 so-called consumers’ durable goods. Mini-
mum down payments which can be accepted for
various goods are also prescribed by the regula-
tions.

The Board has made possible the exemption
of cases which occur because of loans for med-
ical, hospital, dental or funeral expenses which
cannot be reasonably taken care of according to
Regulation “W.” Of course, this ruling may be
altered at any time as the Board sees fit.

NYA HEALTH EXAMINATIONS
DISCONTINUED

B. W. Carey, M.D., recently announced that
the NYA health examinations were discontinued
in Michigan as of July 1, 1941, largely because
of the limitation of the NYA appropriation. In
order to keep the importance of health in the
defense program of the NYA, the “screening
process” is being used, whereby nurses in each
area, who are under the immediate supervision of
a doctor of medicine, will endeavor to pick up the
marked deviations from normal health, and refer
the youth to his private family physician for
diagnosis and treatment. Doctor Carey states em-
phatically that the nurse will not diagnose any
condition, but merely refer youths who because
of obvious defects should have the attention of

their physicians. Doctor Carey is hoping the or-
iginal plan of health examinations of all NYA
enrollees by doctors of medicine may be re-
sumed before too long.

: [V|SMS

ONE EXAMINATION FOR DRAFTEES

A single physical examination for Selective
Service registrants, in lieu of the present dual
examinations conducted by local board physicians
and Army induction stations, will be the pro-
cedure followed throughout the country by Jan-
uary 1, 1942, National Headquarters, Selective
Service System, has announced.

The plan for the single examination provides
that each state be divided into districts, with the
Army physicians conducting examinations of
selectees in each of the districts. In the more
congested areas an examination station will func-
tion at all times, while in the sparsely settled
districts the tests will be given at periodic
intervals.

=|VlSMS

REHABIUTATION OF REJECTED DRAFTEES

“The President of the United States will an-
nounce today that the Selective Service System
has been charged with the administration of a
program for the rehabilitation of rejected men
between the ages of twenty-one and twentj’-eight
found by the army to have remediable defects
and who as a result of such treatment will be made
available for general military service. The remedy
will be provided by physicians and dentists of the
locality in which the registrant resides and com-
pensation will be paid from federal funds to be
made available for such purpose. More detailed
information concerning the plan will be sent at the
earliest opportunity.”

The above telegram from the Selective Serv-
ice Headquarters in Washington, D. C., was re-
ceived by the Michigan Director of Selective
Service on October 10, 1941. At the date The
Journal went to press, no additional informa-
tion had been received in Michigan. When the
details reach the Michigan State Medical So-
ciety headquarters, they will be relayed promptly

Jour. ^^.S.M.S.

920

You Will
Want to Know
About the
Kenny Method

for the

Treatment of
Infantile Paralysis
in the Aeute Stage

by Sister Elizabeth Kenny

of Australia

*See June 7th Issue — Journal American Medical Association

The success of Sister Kenny’s method of treating infantile paralysis
has attracted the attention of medical men throughout the world. Her
work in the past two years, at the University of Minnesota and the
General Hospital in Minneapolis, has demonstrated to the satisfaction of
many prominent physicians that her treatment definitely produces
remarkable results.

Her revolutionary methods, first evolved in the Australian frontier
and later demonstrated in Melbourne, challenged the attention of leading
international poliomyelitis authorities who encouraged her to come to
the United States to continue her work.

This book, containing her lectures, is the only text book on the subject
of her methods. It reveals, for the first time, the history of the develop-
ment of her treatment and its complete explanation written by Sister
Kenny in person, the originator of this method. Completely illustrated
and with full detail, it brings to the medical profession a highly informa-
tive and educational study.

Price $3.50 postpaid. You may order by check
or C. O. D., either from the publisher or from
your book dealer.

BRUCE PUBLISHING COMPANY

2642 University Avenue National Building

Saint Paul, Minnesota Minneapolis, Minnesota

November, 1941

Say you saw it in the Journal of the Michigan State Medical Society

921

YOU AND YOUR BUSINESS

to the secretaries of the fifty-five component
county medical societies.

The Medical Preparedness Committee of the
American Medical Association attended a con-
ference in Washington on Friday, October 17,
relative to the matter of rehabilitation of re-
jected registrants. Reports on this meeting will
be published in The Journal of the American
Medical Association.

= [V|SMS
YOUR INCOME TAX

An authoritative article on the new Income
Tax Law of 1941, as it applies to Doctors of
Medicine, will be published in the December
Journal of the MSMS. The article will not
only explain the provisions of the new law but
also illustrate its workings by many concrete
examples.

: r[V|SMS

MEDICAL WELFARE IN MICfflGAN—

RESULTS OF SURVEY

The following summary of questionnaires re-
cently sent to the secretaries of county medical
societies in Michigan would indicate a grave
lack of uniformity in the handling of medical
welfare in Michigan.

Fifty-five county medical societies reported,
a return of 100 per cent.

In answer to the question : “Is your local

fee schedule for medical care of indigents (in-
cluding afflicted adults) higher or lower on the
average than the present Fee Schedule of the
Michigan Crippled Children Commission ?” ;

One county medical society secretary reported
that his county society has no schedule.

One secretary reported that the work is being
done by salaried physicians (which is contrary
to the Welfare Act of 1939).

Eleven secretaries stated that their local fee
schedules were slightly higher.

Twenty-five secretaries reported that their local
fee schedules were about the same as the M.C.C.
schedule.

Seventeen secretaries reported that their local
fee schedules were low'er (these seventeen coun-
ty medical societies represent 24 Michigan coun-
ties).

Of the seventeen county medical societies with
lower schedules, twelve reported that they are

giving study to plans whereby their members
may be paid at least cost price for medical care
of wards of government. Five reported their
societies are doing nothing about the matter!

=|\/|SMS

PRIVILEGED COMMUNICATION

A physician recently inquired : “Is there any

liability to a physician who gives a copy of a
positive serological examination to an insurance
company ?”

The best rule to apply is for a physician or a
hospital always to request written authorization
from a patient before furnishing an abstract of,
excerpts from, or total history of any patient.

Inasmuch as the privileged communication
statute is very flexible in regard to contagious
and communicable diseases, it stands to reason
that it also would be lenient in regard to reports
of venereal disease in positive patients, especially
if written authorization from the patient was
obtained in advance.

Some statutes state that the privileged com-
munication must be a wilful betrayal of the pro-
fessional secret. A California appelate court
has used the phrase “wilful betrayal,” and it
appears that a disclosure of a diagnosis would
not be prohibited.

Of course, each case is an individual situa-
tion, and what is covered by insurance waivers
to hospitals or doctors would not always hold
good under certain other conditions ; for ex-
ample, a new Supreme Court decision in Cali-
fornia holds that neither a hospital nor a radiol-
ogist may furnish films or a diagnosis on a pa-
tient without the permission of the referring
physician. This is a new law, and the first time
the referring physician has been designated as
having control of the diagnosis.

As a rule, however, the patient’s signing of a
waiver (written authorization) is sufficient pro-
tection for the doctor of medicine and for the
hospital.

=[\/|SMS

MICHIGAN HOSPITALS AND MEDICAL
PAYMENTS PLAN

In accident cases, large numbers of people are
indemnified in whole or in part from insurance
protection. But in countless numbers, the funds
received by the patient are dissipated, and the

Jour. M.S.M.S.

922

YOU AND YOUR BUSINESS

hospital and the doctor remain unpaid despite the
fact that the settlement was predicated, often
in its entirety, upon the medical expenses in-
curred. In other words, the insurance company
paid the patient for the hospital and medical
expense — but the patient went out and bought
a new car instead of paying his just debt to the
doctor and hospital.

To more definitely assure payments to physi-
cians and to hospitals for their services, an agree-
ment called the “Michigan Hospitals and Medi-
cal Payments Plan” has been entered into by the
Michigan State Medical Society, the Michigan
Hospital Association, the American Mutual Al-
liance, the Association of Casualty and Surety
Executives, and a group of Michigan insurance
carriers. This agreement has been in effect since
March 1, 1941. During these seven months,
the cooperation between the above-named groups
has been so perfect and friendly that the Con-
ference Committee, created under the Agree-
ment to arbitrate differences, has not been called
into any case.

The forms to be used in connection with
Michigan Hospitals and Medical Payments Plan
are available through the Executive Office, 2020
Olds Tower, Lansing. When you render service
in an accident case, protect yourself financially
under this agreement (explained in detail in the
February, 1941, MSMS Journal; free reprint
available upon request).

^=|VlSMS__

"INVITE THEM TO JOIN"

“This Society shall consist of active members,
junior members, honorary members, associate
members, retired members and members emeri-
tus,” M.S.M.S. Constitution; Article Three, Sec-
tion One.

The membership of the Michigan State Medi-
cal Society stands at 4,527. Approximately 350
eligible physicians in practice have not as yet
joined a county or the State Society. A high
percentage of these reputable practitioners would
become associated with organized medicine as
Active Members if they received a personal or
telephonic invitation from a member of the Michi-
gan State Medical Society. The matter of dues
need not bother any physician, since the MSMS
assessment for the last quarter of the year to
new members is only $3.00. Invite them to join.

Another group that should be invited to join
are the interns and residents who are now

Did you know
Johnnie Walker
is a dnet?

Johnnie Walker has to be two people. For
the friendly gentleman identifies both 12-
year-old Black Label and 8-year-old Red
Label Scotch whis-
ky. Each has the
smooth, friendly
flavour that brings
a special feeling of
satisfaction to your
taste. You’ll like
mellow Johnnie
Walker, from the
very first sip.

BORN 1820 . . .
Still going strong

WHEREVER YOU ARE
IT'S SENSIBLE TO STICK WITH

I

I

BLENDED SCOTCH WHISKY

BOTH 86.8
PROOF

Canada Dry Ginger
Ale, Inc., New York, N. Y., Sole Importer

November, 1941

923

YOU AND YOUR BUSINESS

*‘He can still chew
but He can*t swaller**

It’s an old Hoosier saying, often as true
of the patient with superficial oral or
pharyngeal pathology as of young glut-
tons. For the former, however, there is
usually relief . . . NUPORALS, “Gib a.”

NUPORALS,* containing one mgm.
of Nupercaine in each lozenge are ef-
fective in allaying pain and tenderness
of the oral and faucial mucous mem-
branes; especially are they indicated
for ameliorating the pharyngeal dis-
tress associated with passing stomach
tubes. Non-narcotic, locally anesthetic
and pleasant to taste.

classed as “Junior Members.” They pay no dues
to the State Society other than the nominal cost
of the MSMS Journal. This new junior mem-
bership was created by the MSMS House of
Delegates in 1940.

Tangible benefits are being received by mem-
bers of the Michigan State Medical Society —
else what can account for the all-time high record
of 4,527 members?

= |V|SMS

IS THE BUSINESS BOOM AFFECTING
YOUR COLLECTIONS?

Almost every physician is busier now than
he has been in years. The same is true of de-
partment stores and other agencies where both
necessities and luxuries are being procured by
men and women, many of whom have exper-
ienced long or short periods of unemployment.

While the doctor’s services are now more
readily sought, reports filter in that the patients’
money again fails to reach the physician. The
doctor continues to be the last to be paid.

Therefore, it is time for a little “examination
of the business conscience” by every physician :

Are you sending statements promptly and
regularly each month, to new and to old ac-
counts alike?

Are you following systematically with letters
and telephone calls if three plain statements
elicit no response?

Have you recently checked your accounts
receivable carefully for accounts that should be
placed for collection ?

Don’t forget. Doctor, that “dead” accounts in
your files are still very much alive so far as
your payment of the Michigan Intangible Tax
on these accounts receivable are concerned !

NUPORALS are supplied in boxes of 15 and
in bottles of 100 lozenges. Samples and more
details upon request.

•Trade Mark Reg. U. S. Pat. Off. The word
"Nuporals” identifies throat lozenges of Ciba’s
manufacture, each lozenge containing one
mgm. of Nupercaine, "Ciba.”

CIBA PHARMACEUTICAL PRODUCTS, INC.

SUMMIT, NEW JERSEY

*nOWHow You stand
Compared with Last Year /

. . . You’d know exactly, at a glance, if you
were using the DAILY LOG. It’s the SIMPLI-
FIED, thoroughly ORGANIZED system of
office bookkeeping. Includes in one neat vol-
ume every essential business rec-
ord of your practice. Important
V non-financial ones, too. It’s a

treasure at income tax time!
WRITE — for illustrated booklet “The
Adventures of Dr. Young in the
Field of Bookkeeping.”

COLWELL PUBLISHING CO.

1 126 University Ave., Champaign, III.

924

Say you saw it in the Journal of the Michigan State Medical Society

Jour. M.S.M.S.

I

1

i

^ Woman’s Auxiliary -K

REPORT OF STATE CONVENTION

Woman's Auxiliary Officers

The 1941 state convention of the Woman’s Auxiliary
to the Michigan State Medical Society was held in
Grand Rapids, September 16-19,
at the Pantlind Hotel.

Great credit is due to Mrs. T.
C. Irwin and the Kent County
group for an outstanding meet-
ing. That much time and great
effort had been put into the task
was quite obvious. Also memor-
able were the charm and gracious
dignity of our president, Mrs. R.
V. Walker.

The business sessions were un-
usually well attended and very in-
teresting. The highlight of the
business meeting was Mrs. Walk-
er’s recommendation that a stu-
dent loan fund, for the children
of physicians, be established. 'The
project met with universal approval and the motion
on the matter was unanimously passed.

It was a great inspiration to the officers, the com-
mittee chairmen and the members to have our Na-
tional President, Mrs. R. E. Mosiman, of Seattle, Wash-
ington, with us for a period of two days. The address
that Mrs. Mosiman gave at our annual banquet will
be of great help to us in our future plans. Health
Education, Hygeia, and Nutrition in Home Defense
were the topics that were stressed.

The county president’s reports were read and the
many projects that are being sponsored by the various
counties were very interesting indeed. Many sugges-
tions as to future projects were outlined, such as col-
lecting unused office coats, nurses’ itniforms and old
medical instruments to be sent to Britain.

Mrs. Wm. J. Butler, incoming president, pointed out
the necessity of helping with “National Defense,”
through the promotion of community health and nu-
trition in home defense. She also told us that plans
were being made for a state-wide subscription cam-
paign for the Bulletin.

Two hundred thirty-eight members registered. Of
course, there were many more who attended the con-
vention but failed to register. The outstanding feature
of our annual banquet was a one-act play directed by
Mrs. Fred C. Brace, a member of the Kent County
Auxiliary. The actors were all physicians and members
of the Kent County Medical Society. We greatly
appreciate their kindness in doing this, and thank them
for such a hilarious performance.

Again this year, we were honored by the presence
of our beloved and charming Honorary President,
Mrs. Guy L. Kiefer. A plaque is to be presented to
Mrs. Kiefer for her devotion to the auxiliary over
such a long period of years.

Respectfully submitted,

Francis Pyle (Mrs. Henry J.),
Secretary

1941-1942

President — Mrs. Wm. J. Butler, Grand Rapids
President-Elect — Mrs. G. L. Willoughby, Flint
Vice President — Mrs. John J. Walch, i^canaba
Secretary — Mrs. Henry J. Pyle, Grand Rapids
Treasurer — ^Mrs. H. L. French, Lansing
Past President — Mrs. Roger V. Walker, Detroit
Honorary President — Mrs. Guy L. Kiefer, East Lansing

Committee Chairmen

Archives — Mrs. L. G. Christian, Lansing

Bulletm — Mrs. John J. Walch, Escanaba

Exhibits — Mrs. Fred J. Melges, Battle Creek

Finance — Mrs. Elmer L. Whitney, Detroit

Historian — Mrs. J. Earl McIntyre, Lansing

Hygeia — Mrs. Sidney La Fever, Ann Arbor

Legislation — Mrs. Roger V. Walker, Detroit

Organisation — Mrs. Oscar D. Stryker, Fremont

Parliamentarian — Mrs. A. V. Wenger, Grand Rapids

Press — Mrs. V. F. Kling, Ionia

Program — Mrs. Galen B. Ohmart, Detroit

Public Relations — Mrs. Mark Osterlin, Traverse City

Revisions — Mrs. C. L. Bennett, Kalamazoo

Special Comm-ittee — Mrs. Paul R. Urmston, Bay City

worth while laboratory exam-
inations; including —

Tissue Diagnosis

The Wassermann and Kahn Tests

Blood Chemistry

Bacteriology and Clinical Pathology

Basal Metabolism

Aschheim-Zondek Pregnancy Test

Intravenous Therapy with rest rooms for
Patients,

Electrocardiograms

Central Laboratory

Oliver W. Lohr, M.D., Director

537 Millard St.

Saginaw

Phone, Dial 2-3893

The pathologist in direction is recop^zed
by the Council on Medical Education
and Hospitals of the A. M. A.

Mrs. Wm. J. Butler,
Grand Rapids,
President, Woman’s
' Auxiliary, MSMS

THE MAPLES

A Private Sanitarium for the Treatment of Alcoholism

Registered by the A.M.A.

R.F.D. 3, LIMA, OHIO
Phone: High 6447

Located Miles East of Corner on
U. S. 30 N.

F. P. Dirlam A. H. Nihizer, MJ).

Superintendent Medical Director

November. 1941

925

MICHIGAN’S DEPARTMENT OF HEALTH

HENRY A. MOYER, M.D^ Commissioner, Lansing, Michigan

g£-s^s-s-fj-s-rrrrf TTrr r r

-K

-K

DIPHTHERIA IN TWO SCHOOLS

Diphtheria was found in two rural schools in Sep-
tember, but in neither case did a local epidemic result.
In a Lenawee county school, four boys and girls from
a Mexican beet worker’s family became ill and were
isolated. Their ages were unusually high for attacks
of diphtheria; 10, 14, 16 and 17 years old. Members
of the family denied any visit to or frorn the migra-
tory camp near Blissfield where diphtheria broke out
among Mexican families in August.

The other school case of diphtheria occurred near
St. Johns in Clinton county, but only a single case was
reported.

OBSTETRICS COURSE IN JANUARY

Another two-week postgraduate course in obstet-
rics is offered for four physicians beginning January
5, 1942, at the University Hospital at Ann Arbor un-
der the combined sponsorship of the University of
Michigan Department of Postgraduate Medicine and
the Michigan Department of Health. Applications
should be sent now to Dr. Lillian R. Smith, direc-
tor of the Bureau of Maternal and Child Health,
Michigan Department of Health, Lansing. There
is no fee for the course. Five physicians finished
one of the courses October 4, 1941.

DEFENSE INDUSTRIES SPEND
$350,000 FOR HEALTH

Michigan industries have spent more than $350,000
in the last fiscal year in carrying into effect sugges-
tions for protecting defense workers from health haz-
ards on the job.

All defense contracts carry a requirement that
the health of employes must be safeguarded during
working hours, and during the 12 months ending
June 30, the Bureau of Industrial Hygiene of the
State Health Department made studies in more
than 500 factories. At the time of the first return
visits of bureau staff members, more than 80 per
cent of the corrections asked for had been made.

So many studies have been requested that they have
been scheduled well into 1942. In response to a re-
quest for assistance, the United States Public Health
Service has loaned the Department a sanitary engineer,
a chemist and an industrial physician.

SEPTEMBER INFANTILE PARALYSIS
UNDER NORMAL

Infantile paralysis cases reported in September totaled
92, only a fifth as many as in September last year
when the state had a record-breaking epidemic. The
total of 92 compared also with a five-year average of
201. Fifty-six of the September cases were from De-
troit.

August cases of polio totaled 59 compared with the
five-year average of 103 and a total of 304 for August
last year.

PHYSICIANS CAN REGISTER
BIRTHS OF YEARS AGO

Family physicians of the older generation often can
give assistance where a birth certificate is not on file
in official records. If a record is missing, the facts
can be established in probate court, but the law also
permits the physician who attended the birth to make
out a certificate even though years may have passed.

There is considerable opportunity for veteran physi-
cians of the state to make out such delayed registra-
tions because birth certificates are necessary for men
and women working on defense jobs. Instructions from
the Bureau of Records and Statistics are that the physi-
cian use a current birth blank in making out a delayed
registration and that he file it with the local registrar
in the usual way. No fee for such a late filing is
required and the original record ultimately reaches the
State Health Department vaults at Lansing.

WHOOPING COUGH COMMUNICABLE
DISEASE NO. 1

Since mid-summer, whooping cough has become the
state’s most prevalent communicable disease and is be-
ing reported at well over a thousand cases a month.
From January through June, deaths totaled 50 com-
pared with 19 in the first six months of 1940.

Vaccine will be used more widely than ever this
fall and winter to protect babies and young chil-
dren against whooping cough. We are getting away
from the old notions that whooping cough is an
unavoidable childhood disease and that it is of lit-
tle danger. Vaccine gives a high degree of pro-
tection against whooping cough and during the last
year the State Health Department laboratories dis-
tributed to physicians enough vaccine for more than
30,000 children. It was the second year of our vac-
cine production and represents an increase of 44
per cent.

Babies and very young children are most in need
of protection, for two-thirds of the state’s whooping
cough deaths occur in babies less than a year old. Aside
from its threat of death, whooping cough is one of the
most troublesome of childhood diseases, for one case
may keep a household upset for a month.

The recommendation of the State Health Depart-
ment, the Michigan branch of the American Academy
of Pediatrics and the Michigan State Medical Society
is that physicians give whooping cough vaccine to babies
at from six to nine months of age. The vaccine can
also be given to children who are ready to enter school.

HEALTH OF DEFENSE WORKERS

Since all defense contracts carry clauses for health
protection of workers, there is special interest now in
the work of the Bureau of Industrial Hygiene. In the
first three months of 1940, 156 plans called for studies
by the bureau, and of the recommended improvements
85 to 90 per cent had been completed by the first of
May.

There is so much demand for studies by the bureau
that in May there was work ahead for four months.
The most common hazard to workers is dust, which
is common in foundries and in factories wherever there
are grinding operations. Consequently, most of the rec-
ommendations of the Department’s industrial hygiene
engineers are concerned with ventilation problems.

Tliis bureau is headed by an industrial hygiene phy-
sician who has a staff of engineers and chemists. The
federal law places responsibility upon the State Health
Department for health conditions in defense factories.
In Detroit, studies are made by the Bureau of Indus-
trial Hygiene of the Detroit Department of Health. Chit-
side Detroit, the State’s studies are made from head-
quarters at Lansing and district offices at Saginaw,
Pontiac and Grand Rapids.

926

Jour. M.S.M.S.

-K COUNTY AND PERSONAL ACTIVITIES ^

Loren W. Shaffer, M.D., Detroit, is co-author of the
article entitled “Massive Dose Therapy in Early
Syphilis” which appeared in The Journal of the
AMA, issue of October 4, 1941.

^ ^ ^

Mt. Carmel Mercy Hospital, Detroit, broke ground
on September 26 for a six-story 200-bed addition. The
new wing will include also several operating rooms

of various types, an enlarged laboratory and pharmacy'

facilities, and an auditorium with a seating capacity of
400 for staff and other types of meetings.

54: :fc ^

The Detroit Diabetes Association held its first meet-
ing on October 8, 1941, at tbe Wayne County iMedical
Soc ety Building, Detroit.

The Association is planning on meeting every second
month or five meetings during the year. Interested phy-
sicians are invited to attend these meetings.

^ ^ ^

R. Philip Sheets, M.D., Medical Superintendent of
Traverse City State Hospital, announced recently the
addition to his staff of Osee Maj- Dill, M.D., and Paul
Wilcox, M.D. Doctor Dill is a graduate of the Indiana
University School and Doctor Wilcox graduated from
the University of Michigan Medical School.

^ ip. 9(i

The Mayo Foundation announces that a series of
lectures, demonstrations and clinics by members of the
faculty and invited guests will be held in Rochester,
Minn., during the week of November 10. Problems

related to medical and surgical emergencies encountered
in civilian and military practice will be emphasized.
Physicians are invited to attend.

* ❖ *

Federal Food, Drug and Cosmetic regulations re-
quire the label “warning, may be habit forming” on a
specific list of drugs used in prescriptions. Unless the
prescription is marked “not to be refilled,” pharmacists
must place the warning label on the prescription.
There are also instances in which a prescription may
not be refilled without verbal or written consent of the
physician.

ip ^ ip

Opening for physician at Ionia State Hospital. Sal-
ary $300 per month, less maintenance for physician and
his family if married. Six room cottage available for
married physician or suitable quarters for a single
man. Excellent opportunity to gain valuable experience
in neuropsychiatry, as well as in other branches of
medicine. Write P. C. Robertson, M.D., Medical Su-
perintendent, Ionia State Hospital, Ionia, Michigan.

ip ip ip

Plans for the 1942 MSMS Convention are already
being developed. The Scientific Program for the 77th
Annual Meeting will feature approximately 75 eminent
lecturers. The exhibit will again be held in the Civic
Auditorium of Grand Rapids. The headquarters will be
at the Pantlind Hotel. The dates ; September 22, 23,
24, 25, 1942.

(DUE TO NEISSERIA GONORRHEAE)

ciTi

ilver Picrate,
Wyeth, has a convincing record of
effectiveness as a local treatment for
acute anterior urethritis caused by
Neisseria gonorrheae.^ An aqueous
solution (0.5 percent) of silver pic-
rate or water-soluble jelly (0.5 per-
cent) are employed in the treatment.

Acomplafe technique of treatment and literature will be sent upon request

‘Silver Picrate is a definite crystalline compound of silver and picric acid.
It is available in the form of crystals and soluble trituration for the prepara-
tion of solutions, suppositories, water-soluble jelly, and powder for vaginal
insufflation.

1. Knight, F., and Shelanski,
H. A., "Treatment of Acute Ante-
rior Urethritis with Silver Picrate,”
Am. J. Syph., Gon. & Ven. Dis.,
23, 201 (March), 1939.

JOHN WYETH & BROTHER, INCORPORATEO, PHILADELPHIA

November, 1941

927

COUNTY AND PERSONAL ACTIVITY

A MODERN, comfortable sanatorium adequately equipped for all types of medical and
surgical treatment of tuberculosis. Sanatorium easily reached by way of Michigan
Highway Number 53 to Comer of Gates St., Romeo, Michigan.

For Detailed Information Regarding Rates and Admission Apply

DR. A. M. WEHENKELy Medical Directory Citjr Officesy Madison 331Z*3

TUBERCULOSIS

.WEHENKEL SANATORIUM

MICH.

ROMEO

RESTFUL

AND

QUIET

PRIVATE

ESTATE

CONVALESCENT
HOME FOR

’‘Shock is one of the most overworked terms in
the medico-legal vocabulary, as many deaths said
to be due to shock should really be ascribed to such
conditions as loss of blood, exhaustion, injury to a
vital organ, concussion of the brain, and so forth.
Cases in which persons can justly be said to owe their
death to shock are comparatively rare.”— Sir Bernard
Spilsbury, “Some Medico-Legal Aspects of Shock,”
Medico-Legal and Criminological Review 1, January,
1934.

♦ * ♦

The U. S. Director of Civilian Defense has appointed
the following Medical Advisory Board to assist the
Medical Division of the Office of Civilian Defense :
George Baehr, M.D., New York, Chairman; Robin C.
Buerki, M.D., Madison, Wisconsin ; Elliott Cutler, M.D.,
Boston, Massachusetts; Oliver Kiel, M.D., Wichita
Falls, Texas; Albert McCown, M.D., Washington, D.
C. ; and Fred Rankin, M.D., Lexington, Kentucky.

The MSMS representative to the Michigan Civil De-
fense Advisory Board is P. R. Urmston, M.D., Bay
City.

Many physicians, as well as other prominent profes-
sional men in Michigan, have recently been circularized
by the “Blue Book and Social Register of America” in
an effort to obtain permission to publish their names
in the so-called register. Inquiries have been directed
to the “Blue Book and Social Register of America”
at its Detroit office in order to obtain more complete
information concerning the project, but the company
has not given the courtesy of a reply, even to the De-
troit Better Business Bureau !

“Before you invest, investigate.”

>!:

Hospital Bed Facilities.- — According to a widespread
survey made of hospital bed facilities in the United
States, released today by the Census Bureau of the

Department of Commerce, 1,282,785 beds were available
in 9,614 institutions for the medical care of the Amer-
ican people in 1939. The country’s 6,991 hospitals and
sanatoriums provided the great bulk of this care — 355,-
145,063 patient-days, or the equivalent of one week-end
stay in the hospital each year for every person in the
United States. Infirmaries and nursing, convalescent,
and rest homes provided the remainder.

Hospitals and sanatoriums had 1,186,262 beds or 92
per cent of the nation’s total. Census Bureau figures
show that the average hospital had 169 beds and
served 5,000 families.

* * *

Surgeon General Thomas Parran of the United States
Public Health Service recently called for 50,000 Avell
educated young women to begin training now for pro-
fessional nursing careers in order to “avert serious dam-
age to the Nation’s health during the present emer-
gency.”

The Surgeon General declared that this large num-
ber of students is needed to meet the tremendous de-
mand for graduate registered nurses as a result of the
national defense program.

The States Relations Division of the United States
Public Health Service is administering a recent Con-
gressional appropriation of $1,250,000 which will fa-
cilitate the training of these additional nurses.

5!= * *

Committees of The Council. — A. S. Brunk, M.D.,
Chairman of The Council, announces the following
committees of The Council for 1941-42;

Fincmee Committee — Vernor M. Moore, AI.D., Grand
Rapids, Chairman ; W. E. Barstow, M.D., St. Louis ;

L. J. Johnson, M.D., Ann Arbor; P. L. Ledwidge,

M. D., Detroit and R. S. Morrish, M.D., Flint. Publica-
tion Committee — Wilfrid Haughey, M.D., Battle Creek,
Chairman ; Otto O. Beck, M.D., Birmingham ; T. E.
DeGurse, M.D., Marine City ; Roy C. Perkins, M.D.,

Tour. M.S.M.S.

928

Say you saw it in the Journal of the Michigan State Medical Society

COUNTY AND PERSONAL ACTIVITY

« Bay City; and Clarence E. Umphrey, M.D., Detroit,
■k] County Societies Committee — E. F. Sladek, M.D., Tra-
k] verse City, Chairman; R. J. Hubbell, M.D., Kalama-
zoo ; W. H. Huron, M.D., Iron Mountain ; A. H. Miller,
M.D., Gladstone ; and Philip A. Riley, M.D., Jackson.

j *

i Your friends

if Abbott Laboratories, North Chicago, Illinois
The Baker Laboratories, Cleveland, Ohio
i Bard-Parker Company, Danbury, Connecticut
jAs Barry Allergy Laboratory, Inc., Detroit, Michigan
III Becton, Dickinson & Company, Rutherford, Newr Jersey
i Rudolph Beaver, Inc., Waltham, Massachusetts
.iji Bilhuber-Knoll Corporation, Orange, New Jersey
*3' Ernst Bischoff Company, Ivoryton, Connecticut
!f; The Borden Company, New York, New York

Burroughs Wellcome & Company, New York, New York

(5' The above ten firms were exhibitors at the 1941 Con-
y vention of the Michigan State Medical Society and
^|1 helped make possible for your enjoyment one of the
outstanding state medical meetings in the country,
'at Remember your friends when you have need of equip-
|ilj ment, medical supplies, appliances or service.

The U. S. Civil Service Commission has made the
following principal changes in its announcement for

!' j new medical officers : the adding of the option “Pub-
‘ lie health, general” to the Senior grade and the option
I “Cancer; (a) Research, (b) Diagnosis and Treat-
ment” to the Medical Officer and Associate grade; the
I provision for the acceptance of aplications for the
I Associate grade from persons who have not yet com-
pleted internship ; the setting back of the date of
graduation for the Associate grade to May 1, 1930; and
the raising of the age limit for all grades to fifty-three.
1 Further information may be obtained from the Com-
; mission’s representative at any first- or second-class
■ post office or from the Central Office at Washington,
: D. C.

Appointments in the Medical Corps, United States
Naval Reserve. — The Surgeon General of the Navy in-
vites the attention of civilian doctors to the opportunity
of becoming commissioned officers of the Medical Corps
in the U. S. Naval Reserve.

Male citizens of the United States, graduates of
class “A” medical schools, who are under 50 years of
age and who meet the physical and professional re-
quirements, are eligible for appointment as commis-
sioned officers in the Medical Corps of the Naval Re-
serve.

Applicants desiring appointments in the Medical
Corps of the Naval Reserve should communicate with
the Commandant, Ninth Naval District, Great Lakes,
Illinois.

* * *

Salmon Memorial Lectures— YmdiX dates for the Sal-
mon Memorial Lectures which Robert D. Gillespie,
M.D., psychiatric specialist of the British Royal Air
Force, will deliver in key cities of this country and
Canada, have been announced by C. Charles Burlington,
M.D., Chairman of the Salmon Committee on Psychia-
try and Mental Hygiene. The schedule of lecture dates
is as follows: New York, November 17, 18; Toronto,
November 19; Chicago, November 21; New Orleans,
November 22; Washington, November 24-25; San Fran-
cisco, November 27; Philadelphia, November 30.

Dr. Gillespie has received special leave of absence
from the RAF from the British government for the
express purpose of delivering the Salmon Lectures in
this country and Canada. He will fly here to make a
first-hand report to members of the American medical
profession and officers of the United States Army and
Navy Morale Division on the psychological effects of
“blitz” warfare on civilian and armed forces.

Dr. Gillespie’s observations made under actual war
conditions are expected to be of inestimable value to

t

t makes their regular check-ups
"fun” by giving youngsters some
wholesome CHEWING GUM

NATIONAL ASSOCIATION OF CHEWING GUM MANUFACTURERS, STATEN ISLAND, NEW YORK

It’s such an easy, thoughtful gesture to always offer
your little patients some delicious Chewing Gum
while they’re waiting or when they leave the office.
They just love it — and it makes a big hit with
adults, too. And for such a small cost this one,
friendly, little act goes a long way in winning extra
good will and affection. Besides, as you know, the
chewing is an aid to mouth cleanliness as well as
helping to lessen tension. Enjoy chewing Gum,
yourself. Get a good month’s worth for your
office today.

There's a reason, a time
and place for Chewing Gum

November, 1941

Say you saw it in the Journal of the Michigan State Medical Society

929

Ferguson -Droste- Ferguson Sanitarium

♦

Ward S. Farcusoiit M. D. Jamaa C. Droste, M. D. Ljrnn A. Fcrcuson, M. D.

PRACTICE LIMITED TO
DIAGNOSIS AND TREATMENT OF

DISEASES OF THE RECTUM

♦

Sheldon Avenue at Oakes

GRAND RAPIDS. MICHIGAN

*

Sanitarium Hotel Accommodations

86c out of each $1.00 gross income
used for members benefit

PHYSICIANS CASUALTY ASSOCIATION
PHYSICIANS HEALTH ASSOCIATION

Hospital, Accident, Sickness

W INSURANCE

For ethical practitioners exclusively
(56,000 Policies in Force)

LIBERAL HOSPITAL EXPENSE
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$50.00 weekly indemnity, accident and sickness

For
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$15,000.00 ACCIDENTAL DEATH
$75.00 weekly indemnity, accident and sickness

For
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per year

39 years under the same management

$2,000,000.00 INVESTED ASSETS
$10,000,000.00 PAID FOR CLAIMS

$200,000 deposited with State of Nebraska for pro-
tection of our members.

Disability need not be incurred in line of duty — benefits
from the beginning day of disability.

Send for applications, Doctor, to

400 First National Bank Building Omaha, Nebraska

LABORATORY APPARATUS

Coors Porcelain
Pyrex Glassware
R. & B. Calibrated Ware
Chemical Thermometers
Hydrometers
Sphygmomanometers

J. J. Baker & Co., C. P. Chemicals
Stains and Reagents •
Standard Solutions

• BIOLOGICALS •

Serums Vaccines

Antitoxins Media

Bacterins Pollens

We are completely equipped and solicit
your inquiry for these lines as well as for
Pharmaceuticals, Chemicals and Supplies,
Surgical Instruments and Dressings.

74, RUPP & BOWMAN CO.

319 SUPERIOR ST., TOLEDO, OHIO

930

Say you saw it in the Journal of the Michigan State Medical Society

Jour. M.S.M.S.

THE DOCTOR’S LIBRARY

American psychiatrists in formulating plans for main-
taining civilian morale in wartime. He will discuss the
problems of psychiatry in national defense under the
title “Psychoneuroses in Peace and War and the
Future of Human Relationships.”

A general invitation to members of the medical pro-
fession and their friends to attend the lecture has been
issued by the Salmon Committee.

THE DOCTOR’S LIBRARY

Acknowledgment of ail books received will be mode in this
column and this will be deemed by us as a full compensation
of those sending them. A selection will be made for review,
as expedient.

THE CARE OF THE AGED. (Geriatrics) By Malford W.
Thewlis, M.D., Attending Specialist, General Medicine, Unit-
ed States Public Health Hospitals, New York City; At-
tending Physician, South County Hospital, Wakefield, R.I. ;
Special Consultant, Rhode Island Department of Public
Health. Third Edition, Entirely Rewritten, with SO illus-
trations. St. Louis: The C. V. Mosby Company, 1941.

Price : $6.00.

It is no longer necessary to justify the specialty or
the fact that special information is needed in the dis-
eases of the aged. The book is well organized and
intelligently written. It is not profusely illustrated
but the typographical setup is excellent. This should
be of value to any general practitioner.

CLINICAL IMMUNOLOGY, BIOTHERAPY AND CHEMO-
THERAPY in the Diagnosis, Prevention and Treatment of
Disease. By John A. Kolmer, M.S., M.D., Dr.P.H., Sc.D.,
LL.D., L.H.D., F.A.C.P., Professor of Medicine, Temple
University School of Medicine ; Director of the Research In-
Institute of Cutaneous Medicine; and Louis Tuft, M.D., As-
sistant Professor of Medicine and Chief of Clinic of Allergy
and Applied Immunology, Temple University School of
Medicine. Philadelphia and London : W. B. Saunders

Company, 1941. Price: $10.00.

These three types of therapy are included in one
volume because of the close relationship of infection,
immunity, biotherapy, and chemotherapy in the diag-
nosis, prevention, and treatment of disease. It is writ-
ten in a more practical form that the usual book cov-
ering these subjects. The summaries presented at the
end of each chapter bring in interesting paragraphs,
important knowledge and evaluations of the present
day. The typography is very good ; it is not extensive-
ly illustrated but splendidly arranged.

HANDBOOK OF COMMUNICABLE DISEASES. By Frank-
lin. H. Top, A.B., M.D., M.P.H., Director, Division of Com-
municable Diseases and Epidemiology, Herman Kiefer Hospi-
tal and Detroit Department of Health; Associate Professor
of Preventive Medicine and Public Health, Wayne Univer-
sity, College of Medicine ; Special Lecturer in Communicable
Diseases and Epidemiology, University of Michigan; Major,
Medical Reserve Corps, United States Army : and collabora-
tory. St. Louis: The C. V. Mosby Company, 1941. Price:
$7.50.

This volume should be of special interest to Michigan
physicians since Dr. Top is the Director of the Division
of Communicable Diseases and Epidemiology at Her-
man Kiefer Hospital and the Detroit Department of
Health. His collaborators are all highly esteemed
medical leaders of Detroit. After a discussion of the
general principles and specific considerations of the
care of these patients the diseases are taken up in a
complete but readable description. It is clearly written
and well outlined. The chapter on syphilis, which was
written by Loren W. Shaffer, presents, in condensed
form, an exceptional presentation of the disease. The
plates are largely colored and all are well selected. The
typography is good and the book is recommended as a
reference book by any general practitioner.

November, 1941

Main Entrance

SAWYER SANATORIUM
White Oaks Farm
Marion, Ohio

For the treatment of
Nervous and Mental Diseases
and Associated Conditions

Licensed for

The Treatment of Mental Diseases
by the Department of Public Welfare
Division of Mental Diseases
of the State of Ohio

Accredited by

The American College of Surgeons
Member of

The American Hospital Association
and

The Ohio Hospital Association

Housebook giving details, pictures,
and rates will be sent upon request.
Telephone 2140. Address,

SAWYER SANATORIUM

White Daks Farm

Marion, Ohio

.Sr;y you saw if in the Journal of the Michigan State Medical Society

931

THE DOCTOR’S LIBRARY

OR safety and reliability use composite Radon seeds in your
cases requiring interstitial radiation. The Composite Radon
Seed is the only type of metal Radon Seed having smooth,
round, non-cutting ends. In this type of seed, illustrated
here highly magnified. Radon is under gas-tight, leak-proof
seal. Composite Platinum (or Gold) Radon Seeds and
loading-slot instruments for their implantation are available
to you exclusively through us. Inquire and order by mail,
or preferably by telegraph, reversing charges.

THE RADIUM EMANATION CORPORATION

GRAYBAR BLDG. Telephone MO 4-6455 NEW YORK, N. Y.

A TEXTBOOK OF BACTERIOLOGY. By R. W. Fair-
brother, D.Sc., M.D., M.R.C.P., Director of the Clinical
Laboratory, Manchester Royal Infirmary ; Special Lecturer
in Bacteriology, University of Manchester; Major, R.A.M.C. ;
Late Research Fellow in Bacteriology, Lister Institute, Lon-
don. Third Edition. St. Louis: The C. V. Mosby Company,
1941. Price: $5.09.

This is an English book printed in the United States.
The material is complete and well organized being more
advanced than the usual American textbook of bac-
teriology. There are a number of excellent colored
plates. The typography is excellent and it is recom-
mended as a reference book as well as a textbook.

fixes the relation of the various clinical laboratory tests
to the patients. It is recommended for any physician
who makes use of laboratory methods in the handling
of his patients.

THE COMPLETE WEIGHT REDUCER. By C. J. Gerling.

New York: Harvest House, 1941. Price: $3.00.

This is a book for popular consumption in which the ■
encyclopedic style is used to present the conservative
viewpoint of various legitimate and fraudulent means •
for reducing weight. The author explodes many of the
superstitions and quackeries and also gives some posi-
tive sane advice and instructions for those desiring to «
reduce.

SYNOPSIS OF APPLIED PATHOLOGICAL CHEMIS-
TRY. By Jerome E. Andes, M.S., Ph.D., M.D., F.A.C.P.,
Director of Elepartment of Health and Medical Advisor, Uni-
versity of Arizona, Tucson; Formerly Assistant Professor of
Pathology and Clinical Pathology, West Virginia University
Medical School; and A. G. Eaton, B.S., M.A., Ph.D., As-
sistant Professor of Physiology, Louisiana State University
School of Medicine, New Orleans. With 23 illustrations. St.
Louis: The C. V. Mosby Company, 1941. Price: $4.00.

This is really a handbook on the application of path-
ological chemistry to clinical medicine. It is very con-
densed, exceptionally complete, and simply arranged.
It avoids most of the controversial points and definitely

NEW AND NONOFFICIAL REMEDIES, 1941. Containing
Descriptions of the Articles Which Stand Accepted by the
Council on Pharmacy and Chemistry of the American Medical
Association on January 1, 1941. Chicago: American Medical
Association, 1941. Price: $1.50.

While this volume lists and describes the articles
which stand accepted by the Council on Pharmacy and
Chemistry of the A.M.A., it also provides a practical
short course in modern therapeutics. It is a much
needed reference book for the physician who prefers
to practice without complete dependence on the detail
man.

fi^Urtiucti, cUiL cUpi/ndaMt

PRESCRIBE OR DISPENSE ZEMMER

Pharmaceuticals . . . Tablets, Lozenges, Ampoules, Capsules,
Ointments, etc. Guaranteed reliable potency. Our products
are laboratory controlled. Write for general price list.

Chemists to the Medical Profession.

MIC 11-41

THE ZEMMER CO., Oakland Sta., Pittsburgh, Pa.

Jour. M.S.M.S.

932

Say you saw it in the Journal of the Michigan State Medical Society

READING NOTICES

I Physicians Heart |
Laboratory

I 523 Professional Building

I 10 Peterboro Street

Detroit, Michigan j

I Laboratory Telephones: TEmple 1-5580 |

Columbia 5580 I

I A laboratory providing the following j
I services exclusively to physicians for their j
I patients: |

I ELECTROCARDIOGRAM I

I BASAL METABOUSM j

j X-RAY of HEART j

I KYMOGRAPH X-RAY of HEART \

\ VITAL CAPACITY \

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I Laboratory Hours: 9 A.M. to 5 P.M. j

• Interpretative opinions and records avail- \

: able only to referring physicians. \

CLASSIFIED ADVERTISING

TEN-BED, BRICK VENEER HOSPITAL and good
general practice to sell. Excellent prospect for a
doctor with moderate capital who likes small town
life and out door activities. Full information can
be obtained by writing to the Executive Office,
Michigan State Medical Society, 2020 Olds Tower,
Lansing, Michigan — Box 19.

* * *

FOR SALE in St. Joseph and Benton Harbor, Michi-
gan, a community of 35,000, office and practice of
the late John A. Schram, M.D. — general practice and
surgery established nine years. Some guaranteed
practice. Five-room office fully equipped, including
x-ray. Address Mrs. John Schram, 1601 Miami Road,
Benton Harbor, Michigan.

When you see one of us on a package of medicine
or food, it means first of all that the manufacturer
thought enough of the product to be willing to have
it and his claims carefully examined by a board of
critical, unbiased experts. . . . We’re glad to tell you
that this product was examined, that the manufacturer
was willing to listen to criticisms and suggestions the
Council made, that he signified his willingness to restrict
his advertising claims to proved ones, and that he will
keep the Council informed of any intended changes in
product or claims. . . There may be other similar
products as good as this one, but when you see us on
a package, you know. Why guess, or why take some-
one’s self-interested word? If the product is everything
the manufacturer claims, why should he hestitate to
submit it to the Council, for acceptance? Mead Johnson
Products are Council-Accepted. ■

November, 1941

DEPENDABLE

L A A T O R Y

to the Medical Profession

WHEN nothing less than a high degree of
accuracy in a clinical test or a chemical
analysis will serve your pu^ose, you can
send us your specimens with confidence.
Pleasant, well-equipped examining rooms
await your patients. In either the zmalytical
or the clinical department of our labora-
tory, your tests will be handled with the
thoroughness and exactitude which is our
undeviating routine. . . Fees are moderate.

Urine Analysis
Blood Chemistry
Hematology
Special Tests
Basal Metabolism
Serology

Parasitology

Mycology

Phenol Coefficients

Bacteriology

Poisons

Court Testimony

Directors: Joseph A. Wolf and Dorothy E. Wolf

kot ^ QQ Jli5t

CENTRAL LABORATORIES

Clinical and Chemical Research
312 David Whitney Bfdg. • Detroit, Michigan
Telephones: Cherry 1030 (Res.) Davison 1220

Cook County

Graduate School of Medicine

(In Affiliation with Cook County Hospital)

Incorporated not for profit
ANNOUNCES CONTINUOUS COURSES

SURGERY — Two Weeks’ Intensive Course in Surgical
Technique with practice on living tissue, starting every
two weeks. General Courses One, Two, Three and
Six Months ; Clinical Courses ; Special Courses.
Rectal Surgery every week.

MEDICINE — Two Weeks’ Intensive Course in Internal
Medicine, and Two Weeks’ Course in Gastro-Enterology
will be offered twice during the year 1942, dates_ to
be announced. One Month Course in Electrocardiog-
raphy and Heart Disease every month, except De-
cember.

FRACTURES & TRAUMATIC SURGERY— Two
Weeks’ Intensive Course will be offered four times
during the year 1942, dates to be announced. In-
formal Course available every week.

GYNECOLOGY — Two Weeks’ Intensive Course will be
offered four times during the year 1942, dates to be
announced. Clinical and Diagnostic Courses every
week.

OBSTETRICS — Two Weeks’ Intensive Course will be
offered twice during the year 1942, dates to be an-
nounced. Informal Course every week.

OTOLARYNGOLOGY — Two Weeks’ Intensive Course
will be offered twice during the year 1942, dates to
be announced. Clinical and Special Courses starting
every week.

OPHTHALMOLOGY — Two Weeks’ Intensive Course
will be offered twice during the year 1942, dates to
be announced. Informal Course every week.

ROENTGENOLOGY — Courses in X-ray Interpretation,
Fluoroscopy, Deep X-ray Therapy every week.

General, Intensive and Special Courses in All Branches

of Medicine, Surgery and the Specialties.

TEACHING FACULTY — ATTENDING
STAFF OF COOK COUNTY HOSPITAL

Address: Registrar, 427 S. Honore St., Chicago, 111.

933

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Kahn and Kline Test
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Complete Blood Chemistry
Tissue Examination
Allergy Tests
Basal Metabolic Rate
Autogenous Vaccines

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Grand Circus Park

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Complete Urine Examina-
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Ascheim-Zonde

(Pregnancy)

Smear Examination
Darkfield Examination

All types of mailing containers supplied.
Reports by mail, phone and telegraph.

Write for further information and prices.

The Mary E. Pogue School

For Exceptional Children

DOCTORS: You may continue to super-
vise the treatment cmd care of children
you place in our school. Catalogue on
recpiest.

WHEATON, ILLINOIS

85 Geneva Road Telephone Wheaton 66

C^jective^, €onmnient
and £conomicai

The eflfectiveness of Mercurochrome has been
demonstrated by twenty years' extensive clinical use.

For the convenience of physicians Mercurochrome
is supplied in four forms — Aqueous Solution for
the treatment of wounds. Surgical Solution for
preoperative skin disinfection. Tablets and Powder
from which solutions of any desired concentration
may readily be prepared.

In Lansing

HOTEL OLDS

Fireproof

400 ROOMS

(dibrom-oxymercuri-fluorescein-sodium)

is economical because solutions may be dispensed
at low cost. Stock solutions keep indefinitely.

Mercurochrome is accepted by the
Council on Pharmacy and Chemistry of
the American Medical Association.

Literature furnished on request

HYNSON, WESTCOTT & DUNNING, INC.

BALTIMORE, MARYLAND

DcNIKE SANITARIUM, Inc.

Established 1893

EXCLUSIVELY for the TREATMENT of
ACUTE and CHRONIC ALCOHOLISM

626 E. GRAND BLVD.

DETROIT

Telephones: Plaza 1777-1778 and Cadillac 2670

A. JAMES DeNIKE, M.D., Medical Superintendent

934

Say you saw it in the Journal of the Michigan State Medical Society

Jour. M.S.M.S.

CONSIDERED

CIGARETTE SMOKING?

and the nicotine content of the smoke of Camels were compared to
the averages of the other brands tested.

The results paralleled the findings of prominent medical— scientific
authorities.* Here is the most important conclusion :

THE SLOWER-BURNING CIGARETTE
PRODUCES LESS NICOTINE IN THE SMOKE

This research also suggests that by advising patients to smoke slower-
burning Camels, it is possible to reduce the nicotine content of
cigarette smoke without sacrifice of smoking pleasure. Thus, the
patient’s cooperation is assured.

A RECENT ARTICLE by a well-known physician in a leading national
medical journal** presents new and important information on this subject,
together with other data on the significance of the burning rate of cigarettes.

There is a comprehensive bibliography. Let us send you this impressive
article for your own inspection. Write to Camel Cigarettes, Medical Rela-
tions Division, 1 Pershing Square, New W)rk City.

*J.A.M.A., Vol. 93, No. 15, p. 1110, Oct. 12, 1929
Bruckner, Die Biochemie des Tabaks, 1936

**The Military Surgeon, Vol. 89, No.l, p. 7, July, 1941

December, 1941

Say you saw it in the Journal of the Michigan State Medical Society

941

Michigan State Medical Society

OFTICERS OF SECTIONS

General Practice

Arch Walls, Chairman Detroit

H. B. Zemmer, Secretary Lapeer

General Medicine

Gordon B. Myers, Chairmamr Detroit

H. M. Pollard, Secretary ... .Ann Arbor

Surgery

Roger V. Walker, Chairman Detroit

Robert H. Denham, Secretary

Grand Rapids

Gynecology and Obstetrics

Robert B. Kennedy, Chairman. .. .Detroit
Roger S. Siddall, Secretary Detroit

Pediatrics

John Sander, Chairman Lansing

Leon DeVel, Secretary ... .Grand Rapids

Legislative

H. A. Miller, Chaimum Lansing

A. S. Brunk Detroit

H. H. Cummings Ann Arbor

Lawrence A. Drolett Lansing

T. K. Gruber EJoise

W. S. Jones Menominee

S. L. Loupee Dowagiac

G. L. McClellan Detroit

Harold Morris Detroit

Elmer W. Schnoor Grand Rapids

Oscar D. Stryker Fremont

Roger V. Walker Detroit

Distribution of Medical Care

Shattuck W. Hartwell, Chairman ....

Muskegon

A. F. Bliesmer St. Joseph

T. S. Conover Flint

Harry F. Dibble Detroit

G. B. Saltonstall Charlevoix

Wm. P. Woodworth Detroit

H. B. Zemmer Lapeer

Joint Committee on Health
Education

Burton R. Corbus (1943) Chairman

Grand Rapids

L. W. Hull (1942) Detroit

Henry A. Luce (1946) Detroit

F. J. O’Donnell (1945) Alpena

W. R. Vaughan (1944) Plainwell

Medical Legal

S. W. Donaldson, Chairmam. .Ann Arbor

Don V. Hargrave Eaton Rapids

R. R. Howlett Caro

Wm. J. Stapleton, Jr Detroit

Preventive Medicine

Wm. S. Reveno, Chairman Detroit

J. D. Bruce Ann Arbor

Burton R. Corbus Grand Rapids

Wm. A. Hyland Grand Rapids

M. R. Kinde Battle Creek

Henry A. Luce Detroit

R. J. Mason Birmingham

Richard M. McKean Detroit

J. Duane Miller Grand Rapids

H. Allen Moyer Lansing

Frank Van Schoick Jackson

Harold W. Wiley Lansing

A. R. Woodburne Grand Rapids

Cancer

Wm. A. Hyland, Chairman

Grand Rapids

John H. Cobane Detroit

F. A. Coller Ann Arbor

W. G. Gamble Bay City

Clyde K. Hasley Detroit

A. B. McGraw Detroit

Wm. R. Torgerson Grand Rapids

Carl V. Weller Ann Arbor

Maternal Health

Harold W. Wiley, Chairman. .. .Dansing

D. C. Blomendaal Zeeland

Max R. Burnell Flint

N. F. Miller Ann Arbor

Harry A. Pearse Detroit

Ward F. Seeley Detroit

Alexander M. Campbell, Advisor. . . .

Grand Rapids

Ophthalmology and
Otolaryngology

F. Bruce Fralick, Chairman. .Ann Arbor

A. E. Hammond, Secretary Detroit

Don M. Howell, Vice Chairman. .. .Alma
Andre Cortopassi, Secretary Saginaw

Dermatology and
Syphilology

Claud Behn, Chairman Detroit

Frank Stiles, Secretary Lansing

Radiology, Pathology and
Anesthesia

Frank Murphy, Chrm. (Anes. ).. Detroit
Donald C. Beaver, Secy. (Path) .. Detroit
Leland E. Holly, Secy. (Rad.) .Muskegon

COMMITTEE PERSONNEL

Syphilis Control

A. R. Woodburne, Chairman

Grand Rapids

Claud W. Behn Detroit

R. S. Breakey Lansing

Eugene Hand Saginaw

L. W. Shafifer Detroit

Tuberculosis Control

M. R. Kinde, Chairman. .. .Battle Creek

John Barnwell Ann Arbor

L. E. Holly Muskegon

W. L. Howard Battle Creek

Willard B. Howes Detroit

Bruce H. Douglas, Advisor Detroit

Industrial Health

J. Duane Miller, Chairman

Grand Rapids

Henry Cook Flint

H. H. Gay Midland

K. E. Markuson Lansing

Frank T. McCormick Detroit

C. D. Selby Detroit

George VanRhee Detroit

Mental Hygiene

Henry A. Luce, Chairman Detroit

R. G. Brain Flint

R. W. Waggoner Ann Arbor

Arch Walls Detroit

O. R. Yoder Ypsilanti

Child Welfare

Frank Van Schoick, C/toiVman. .Jackson

W. C. C. Cole Detroit

Leon DeVel Grand Rapids

Campbell Harvey Pontiac

R. M. Kempton Saginaw

Edgar Martmer Grosse Pointe

Charles F. McKhann Ann Arbor

Iodized Salt

F. B. Miner, Chairman Flint

Thomas B. Cooley Detroit

L. W. Gerstner Kalamazoo

David Levy Detroit

R. D. McClure Detroit

R. C. Moehlig Detroit

H. A. Towsley Ann Arbor

Heart and Degenerative Diseases

R. M. McKean, Chairman Detroit

S. S. Altshuler Detroit

B. B. Bushong Traverse City

M. S. Chambers Flint

John Littig Kalamazoo

M. P. Meyers Detroit

E. D. Spalding Detroit

H. H. Riecker, Adinsor Ann Arbor

Radio

R. J. Mason, Chairman Birmingham

Richard A. Burke Negaunee

Dean W. Hart St. Johns

E. A. Oakes Manistee

G. C. Penberthy Detroit

G. M. Waldie Ishpeming

Ethics

Clarence E. Toshach, Chairman

Saginaw

Wm. H. Alexander Iron Mountain

M. G. Becker Fldmore

F. M. Doyle Kalamazoo

Geo. B. Hoops Detroit

J. J. McCann Ionia

H. W. Porter Jackson

DELEGATES TO A,M.A.

Delegates

Henry A. Luce, Detroit 1942

T. K. Gruber, Eloise 1942

Claude R. Keyport, Grayling 1942

L. G. Christian, Lansing 1943

Frank E. Reeder, Flint 1943

Alternate Delegates

Carl F. Snapp, Grand Rapids 1942

C. S. Gorsline, Battle Creek 1942

R. H. Denham, Grand Rapids 1942

R. H. Pino, Detroit 1943

I. W. Greene, Owosso 1943

Postgraduate Medical Education

J. D. Bruce, Chairman (1942)

Ann Arbor

A. P. Biddle (1942) Detroit

H. H. Cummings (1942) Ann Arbor

Douglas Donald (1944) Detroit

Henry A. Luce (1942) Detroit

W. B. Fillinger (1943) divid

C. L. Hess (1943) Bay City

Edgar H. Norris (1944) Detroit

Ralph H. Pino (1944) Detroit

D. C. Stephens (1942) Howell

Wm. E. Tew (1943) Bessemer

J. J. Walch (1944) Escanaba

Public Relations

H. S. Collisi, Ctvairman. . .Grand Rapids
A. E. Catherwood Detroit

C. G. Clippert Grayling

John S. DeTar Milan

H. C. Hill HoweU

A. H. Miller Gladstone

Fred Reed Three Rivers

D. R. Smith Iron Mountain

A. W. Strom Hillsdale

Advisory to Woman's Auxiliary

A. V. Wenger, Chairman. .Grand Rapids
C. W. Brainard Battle Credr

G. F. Fisher Hastings

L. C. Harvie Saginaw

Wm. S. Jones Menominee

R. F. Salot Mt. Clemens

Medical Preparedness

P. R. Urmston, Chairman Bay City

F. G. Buesser Detroit

L. Fernald Foster Bay City

Harold A. Furlong Lansing

C. D. Moll Detroit

C. I. Owen Detroit

H. H. Riecker Ann Arbor

J. G. Slevin Detroit

Representatives to Conference
Committee on Prelicensure
Medical Education

Burton R. Corbus, Chairman

Grand Rapids

L. Fernald Foster Bay City

J. M. Robb Detroit \

Scientific Work

L. Fernald Foster, Chairman .. .Bay City V

Ruth Herrick, Secretary . .Grand Rapids

Donald C. Beaver Detroit '

Claud W. Behn Detroit

Andre Cortopassi Saginaw

Robert H. Denham Grand Rapids

Leon DeVel Grand Rapids

F. Bruce Fralick Ann Arbor '

A. E. Hammond Detroit 1

Leland E. Holly Muskegon J

Don M. Howell Alma

Robert B. Kennedy Detroit V

Frank Murphy Detroit

Gordon B. Myers Detroit

H. M. Pollard Ann Arbor

John Sander Lansing

Roger S. Siddall Detroit

Frank Stiles Lansing

Roger V. Walker Detroit

Arch Walls Detroit

H. B. Zemmer Lapeer

Tour. M.S.M.S.

942

ENZYMOL

A Physiological Surgical Solvent

Prepared Directly From the Fresh Gastric Mucous Membrane

ENZYMOL proves of special service in the treatment of pus cases.

EINZYMOL resolves necrotic tissue, exerts a reparative action, dissipates foul odors;
a physiological, enzymic surface action. It does not invade healthy tissue; does not
damage the skin. It is made ready for use, simply by the addition of water.

These ore some notes of clinical application during many years:

Abscess cavities
Antrum operation
Sinus coses
Comeal ulcer

Carbuncle
Rectal fistula
Diabetic gangrene
After removal of tonsils

After tooth extraction
Cleansing mastoid
Middle ear
Cervicitis

Originated and Made by

Fairchild Bros. & Foster

I¥ew York, X.Y.

Descriptive Literature Gladly Sent on Request.

ZOALITE

INFRA-RED LAMPS

INFRA-RED IN

COLDS AND SINUSITIS

The following references to infra-red in upper respiratory
infections are indicative of the adjunctive value of this
form of therapy:

”... a great aid . . ." (1)

”. . . will be found helpful . . ." (2)

". . . will relieve the pain and congestion . . ." (3)

“. . . to relieve pain . . ." (4)

For your sinusitis and common cold patients this winter, you can
prescribe a Zoalite Prescription Lamp. We will deliver a Zoalite
promptly at low rental cost to the patient.

1. Haiman, Archives of Phy. Therapy, Aug., 1940.

2. Jervey, So. Med. Jl., Mar., 1939.

3. Schmidt, Pennsylvania Med. Jl., Aug., 1939.

4. Dunaway, Jl. Fla. Med. Assn., Sept., 1940.

THE G. A. INGRAM COMPANY

4444 Woodward Ave. Detroit, Michigan

The G. A. INGRAM CO.. 4444 Woodward Ave., Detroit. Michigan
Please send me information on Zoalite Infra-Red Lamps.

Dr

Address

City State ....

December, 1941

Say you saw it in the Journal of the Michigan State Medical Society

943

C^ountif 3ocietie6

Branches of the Michigan State Medical Society

Alleean

R. J. Walker, President Saugatuck

E. B. Johnson, Secretary Allegan

Alpena-Alcona-Presque Isle

H. J. Burkholder, President Alpena

Harold Kessler, Secretary Alpena

Barry

C. A. E. Lund, President Middleyille

A. B. Gwinn, Secretary Hastings

Bay-Arenac-I osco

R. N. Sherman, President Bay City

L. Fernald Foster, Secretary Bay City

Berrien

A. F. Bliesmer, President St. Joseph

Richard Crowell, Secretary St. Joseph

Branch

F. L. Phillips, President Bronson

H. R. Mooi, Secretary Union City

Calhoun

Harry F. Becker, President Battle Creek

Wilfrid Haughey, Secretary Battle Creek

Cass

Geo. Loupee, President Dowagiac

John K. Hickman, Secretary Dowagiac

Chippewa-Mackinac

B. T. Montgomery, President Sault Ste. Marie

L. J. Hakala, Secretary Sault Ste. Marie

Clinton

W. B. McWilliams, President Maple Rapids

T. Y. Ho, Secretary St. Johns

Delta-Schoolcraft

N. J. Frenn, President Bark River

A. C. Bachus, Secretary Powers

Dickinson-Iron

R. E. White, President Stambaugh

E. B. Andersen, Secretary Iron Mountain

Eaton

C. J. Sevener, President Charlotte

B. P. Brown, Secretary Charlotte

Genesee

D. R. Wright Flint

John S. Wyman, Secretary Flint

Gogebic

W. E. Tew, President Bessemer

F. L. S. Reynolds, Secretary Iron wood

Grand-Traverse-Leelanau-Benzie

James W. Gauntlett, President Traverse City

I. H. Zielke, Secretary Traverse City

Gratiot-Isabella-Clare

R. L. Waggoner, President St. Louis

E. S. Oldham, Secretary Breckenridge

Hillsdale

H. F. Mattson, President Hillsdale

A. W. Strom, Secretary Hillsdale

Houghton-Baraga-Keweenaw

A. C. Roche, President Calumet

Paul Sloan, Secretary Houghton

Huron

J. Bates Henderson, President Pigeon

Roy R, Gettel, Secretary Kinde

Ingham

Harold W. Wiley, President Lansing

R. J. Himmelberger, Secretary Lansing

lonia-Montcalm

L. L, Marston, President Lakeview

John J. McCann, Secretary Ionia

Jackson

A. M. Shaeffer, President Jackson

H. W, Porter, Secretary Jackson

Kalamazoo

Charles L. Bennett, President Kalamazoo

Hazel R. Prentice. Secretary Kalamazoo

Kent

P. L. Thompson, President Grand Rapids

Frank L. Doran, Secretary Grand Rapids

Lapeer

D. J, O’Brien, President Lapeer

H. M. Best, Secretary Lapeer

Lenawee

Bernard Patmos, President Adrian

Esli T. Morden, Secretary Adrian

Livingston

H. G. Huntington, President Howell

Harold C. Hill, Secretary Howell

Luce

Wm. R. Purmort, President Newberry

R. E. Gibson, Secretary Newberry

Macomb

R. F. Salot, President Mt. Clemens

D. Bruce Wiley, Secretary Utica

Manistee

E. B. Miller, President Manistee

C. L. Grant, Secretary Manistee

Marquette- Alger

F. A. Fennig, President Marquette

D. P. Hombogen, Secretary Marquette

Mason

W. S. Martin, President Ludington

Chas. A. Paukstis, Secretary Ludington

Mecosta-Osceola-Lake

V. J. McGrath, President Reed City

Glenn Grieve, Secretary Big ^pi(fs

Medical Society of North Central Counties
(Otsego-Montmorency-Crawford-Oscoda-Roscommon-Ogemaw-
Gladwin-Kalkaska)

Stanley A. Stealy, President Grayling

C. G. Clippert, Secretary Grayling

Menominee

H. T. Sethney, President Menominee

Wm. S. Jones, Secretary Menominee

Midland

Melvin Pike, President Midland

H. H. Gay, Secretary Midland

Monroe

Vincent L. Barker, President Monroe

Florence Ames, Secretary Monroe

Muskegon

Roy Herbert Holmes, President Muskegon

Leland E. Holly, Secretary Muskegon

Newaygo

B. F. Gordon, President Newaygo

W. H. Barnum, Secretary Fremont

Northern Mich. (Antrim-Charlevoix-Emmet-Cheboygan)

G. B. Saltonstall, President Charlevoix

A. F. Litzenburger, Secretary Boyne City

Oakland

Leon F. Cobb, President Pontiac

John S. Lambie, Secretary Birmingham

Oceana

Charles Flint, President Hart

W. Gordon Robinson, Secretary Hart

Ontonagon

J. L. Bende^ President Mass

R. J. Shale, Secretary Ontonagon

Ottawa

C. E. Long, President Grand Haven

D. C. Bloemendaal, Secretary Zeeland

Saginaw

L. A. Campbell, President Saginaw

R. S. Ryan, Secretary Saginaw

Sanilac

H. H. Learmont, President Croswell

E. W. Blanchard, Secretary Deckerville

Shiawassee

Walter S. Shepherd, President Owosso

Richard J. Brown, Secretary Owosso

St. Clair

W. H. Boughner, President Algonac

Jacob H. Burley, Secretary Port Huron

St. Joseph

F. D. Dodrill, President Three Rivers

John W. Rice, Secretary Sturgis

Tuscola

*W. P. Petrie, President Caro

W. W. Dickerson, Secretary Caro

Van Buren

Edwin Terwilliger, President South Haven

J. W. Iseman, Secretary Paw Paw

Washtenaw

Wm. M. Brace, President Ann Arbor

R. K. Ratliff, Secretary Ann Arbor

Wayne

C. E. Simpson, President Detroit

E. A. Osius, Secretary Detroit

Wexford-Missaukee

E. McManus, President Mesick

B. A. Holm, Secretary Cadillac

*Deceased May 14, 1941

944

Jour.

MUI KUHun, M.~| ^

,e C.nle.e~e. M.„ .

about Vitamin Z . .

„rt,_the doctors, nutntiom^s,

<•1 suggest that the career consumers -also

educators, home econ advertisers remember, o

have forgotten a ^ ^^t eating ought to be fum

experts have often to g ^ j ^ when its selec

SUhingfreque^^^^^^ ,,parh Food lo^s

tion is distilled through the ~ p„comfortaWe

its gastronomic gusto. A fel g a„d he

feeling that he is ,® • fclaustrophob^ about it. An

develops a sort of technologica ^ansti-

Indiana farm dinner, ® of vitamins ever strimg

iutes about the best the kind of a vita-

together. That kind of a ^'U _ ^^0 psychological

rar’ori^mrs:;isfa"ion. m name it Vitamin Z.

Apples furnish Vitamins, Minerals, Pectin, Non-
Irritating Bulk. Good for you . . . and good to eat.

MICHIGAN STATE APPLE COMMISSION

LANSING, MICHIGAN

^ MICHIGAN

FOR JUICE . . . FLAVOR . . . HEALTH

December, 1941

Say you saw it in the Journal of the Michigan State Me-dical Society

945

MICHIGAN MEDICAL SERVICE

During the last year the rapid growth of
Michigan Medical Service has resulted in admin-
istrative problems which have been the cause of
some criticism. In a direct approach to these
problems, the Board of Directors of Michigan
Medical Service at its last meeting appointed
Mr. Jay C. Ketchum of Lansing to serve as
Manager of M.M.S. Mr. Ketchum has served as
Deputy Commissioner and Director of Casualty
Insurance under Commissioner of Insurance Eu-
gene P. Berry. He also has had several years’
experience as Chief Examiner for the Insurance
Department, and as an executive with the Great
Lakes Casualty Company, Dearborn National In-
surance Company, and other Michigan organiza-
tions. He is a native of Michigan and well
known in national insurance circles.

Mr. Ketchum’s appointment with complete au-
thority over all administrative phases of the op-
eration of Michigan Medical Service, will iron
out matters of administrative policy, recently the
subject of controversy.

In order to reestablish the schedule of benefits
at 100%, an increase in subscription rates of ap-
proximately 25% has been instituted (from 40c
to 50c). If actuarial data in the next few months
indicate the need for a still higher rate, this will
be provided.

The program of Michigan Medical Service
which was passed almost unanimously by the
House of Delegates and given to the Board of
Directors of the Corporation to operate, has pre-
sented many complicated and involved problems.
The changes already made and those contemplat-
ed indicate the eagerness of the Board of Direc-
tors of M.M.S. to develop practical mechanics
agreeable to all.

General Motors Coverage

Michigan Medical Service reports an encour-
aging decrease (almost 1,000) in the number of
cases reported in September. If this improved
picture continues, M.M.S. will be able to return
to full payment of physicians’ fees according to
its schedule of benefits.

Surgery in the general population runs only
40 cases per 1,000, whereas surgery with Michi-
gan Medical Service groups has been running to
139 cases per 1,000. This experience in the first

six months of newly enrolled groups taxes se-
verely the reserves of Michigan Medical Service
but incidentally reveals that 314 times more ,
operations are performed under the M.M.S. pro- '
gram than are performed in the general popula-
tion.

Since the beginning of Michigan Medical Serv-
ice twenty months ago, the rapid acquisition of ;
numerous large groups has caused the high in- J
cidence of services rendered and has been largely \
responsible for the proration of the schedule ;
of benefits. Obviously, when the seasoning pe-
riod (the initial period of high demand) will have
been passed, the full schedule of benefits can be
reinstated and sufficient reserves developed to
allow for the payment of the percentage with-
held (20 per cent). In General Motors and pre-
viously enrolled groups, a small percentage of
subscribers over the income limits has been en-
rolled. Their identification cards will be clearly i
marked to indicate this fact, in which case the
physician is permitted to charge the difference,
if any, between his usual private fee for persons s
in this group and the schedule of benefits of
M.M.S. Subscribers definitely understand this i
provision and are satisfied with the arrangement.

The GM employes’ participation in a com-
mercial insurance program during the past two
years makes them a well-seasoned group which
should result in a low incidence of service de-
mands.

It much be appreciated that Michigan Medical
Service is a young corporation and that per-
fection can be had only through a process of
evolution. Its initial development was occasioned
by a consumer demand for a program protecting
the low-income workers against catastrophic ill-
ness. This demand will have to be met. either
by cooperative efforts of the medical profession,
or by political or social agencies. Would a
political or social program be consistent with
the democratic practice of medicine and preserve
its traditions?

100 Per Cent Payments

Payments for October services were made by
Michigan Medical Service according to 100 per
cent of its Schedule of Benefits.

946

Tour. M.S.M.S.

Mapharsen offers a record for effectiveness and
safety as an antiluetic which has not been surpassed
by any other arsenical since the days of Ehrlich. The
proof lies in the more than ten million intravenous
injections administered over a seven year period.

Directly spirocheticidal without chemical change
within the body, Mapharsen exhibits relatively con-
stant parasiticidal value. It makes possible intensive
action against the spirochete with comparatively
small doses of arsenic. Untoward reactions are
fewer and less severe than those attending use of
arsphenamine and neoarsphenamine.

Convenience and ease mark the preparation of
Mapharsen solutions. Mapharsen dissolves readily
in distilled water to form a neutral solution isotonic
with the blood — no neutralization required.

Mapharsen (meta-amino-para-hydroxy-phenylar-
sine oxide hydrochloride) contains 29 per cent arsenic
in trivalent form. It does not become more toxic in
the ampoule, in the solution, in the body, or when
exposed to air.

Supplied in 0.04 Gm. and 0.06 Gm. single-dose ampoules,
and in 0.4 Gm. and 0.6 Gm. multiple-dose (10 dose) ampoules.

MAPHARSEN

I A product of modem research offered |

I to the medical profession by

[ PARKE, DAVIS & COMPANY

I DETROIT, MICHIGAN

December, 1941

Say you sazu it in the Journal of the Michigan State Medical Society

947

}

«f

>f HALF A CENTURY AGO >f

LA GRIPPE*

B. B. GODFREY. M.D.
Hudsonville, Michigan

Without giving the history of this disease, I will be-
gin this paper by asserting that I believe la grippe
should be classed with zymotic diseases.

Having this epidemic among us, how shall we diag-
nose it and how treat it?

Probably as safe and scientific a procedure in diag-
nosing this disease, until the microscopist shall have
been successful in discovering the microbe and isolat-
ing its ptomaine or poison, is by elimination. Exclude
bronchitis, asthma, and malaria, and, with the patient
complaining of headache, a sense of construction of the
thoracic muscles, labored breathing, dizziness, loss of
appetite, and almost invariably constipation, with more
or less prostration, and the characteristic “pain all over,”
and you are reasonably sure of a case of la grippe.
I have seen some cases where the patient seemed suf-
fering as from shock ; later, very high temperature
with profuse sweating. In some, the heart fails to do
its duty, and in a number of cases with hyperpyrexia
have the patients become delirious, later more or less
bronchial trouble, with, now and then, a case compli-
cated with pneumonia.

It has been said that this disease indiscriminately
manifests itself among the strong and well, the weak
and diseased. This, my experience tells me, is not true.
I have yet to see the first case where the patient was,
prior to his attack, in a condition approaching that of
normal ; he may, to casual appearance, be well, but a
few questions will convince one that the system was
not in equilibrium, that the balance was overburdened
on one side with some systemic product not appropri-
ated or eliminated, leaving the subject in a proper
condition for some zymotic disease.

With these conditions, what are the indications?

Ostensibly to restore the patient to a normal condi-
tion; but how? It has been my practice almost in-
variably, to give calomel, or its nephew, gray powder,
with an alkali, and get a free movement of the bowels
and stimulate the kidneys and other glands of the
system. This I do, believing the mercury not only does
this but acts as a germicide. For pain I give acetanilide
or antikamnia, and while subduing that, at the same
time and by the same means, reduce the temperature
if necessary. In one instance I found it necessary to
place my patient on ice (the temperature remaining
for three days above 105° F., with constant delirium).
This I did by putting pounded ice on a blanket, fold-
ing it, and then placing the patient on this bed of ice
extending the length of the spine. All other means

^Delivered at the Twenty-Sixth Annual Meeting of the Michi-
gan State Medical Society held at Saginaw, June, 1891.

948

at my hands failed to tranquilize the patient or reduce
the temperature, but in six hours my patient was in
a fair way to recovery, and in a few days was up, but
very weak. In those cases of nervous manifestations,
and we get many of them, I have found the bromides
of little utility, some preparation of morphine answer-
ing the purpose better. In case of heart failure, digi-
talis, as a heart stimulant, with carbonate or muriate
of ammonia for the almost always attendant bronchial
symptoms, are indicated. Quinine has been lauded by
some, but at my hands has not been beneficial, except
when this disease has been complicated with malaria,
which, in some localities, is frequently the case. On the
other hand, I am quite sure I have seen some serious
results from over-dosing with this drug, combined
with whisky, which, last year in particular, was a popu-
lar remedy with the laity. Many of the patients, while
convalescing, were greatly benefited by Scott’s emulsion,
though generally some simple tonic would be all that
seemed necessary, with hygienic surroundings and a
liberal diet of nutritious food.

Discussion

Dr. Henry B. Baker: I can hardly Irope to say very
much on this subject that will be of practical use to
you as practitioners; but I would like to present some
facts that have come to my notice, because of the re-
ports from practitioners throughout the State. Most
of you know that a large number of the leading prac-
titioners of the State report to the State Board of
Health, once a week, the diseases which come under
their observation. These reports are compiled, and
tables made, and diagrammatic curves are made, showing
the increase and decrease, the rise and fall, of each of
the important diseases. The disease called, by the
author of the paper, la grippe, is not often reported
under that name. It has been reported to the State
Board of Health as influenza. It seems to me that
this is a good name for the disease. If the disease
which many of the leading practitioners in Michigan
report to the State Board of Health as influenza is la
grippe, then we have a picture of that disease as it is
found in the state ; and if it is, as the author of the
paper expresses the belief, a communicable disease,
zymotic, its specific cause must be one that is constantly
present in the State of Michigan, for the reason that
the reports to the State Board of Health show that
the disease is present in Michigan in every month in
every year. I have made no special preparation to
speak on this subject ; in fact, I did not know, or had
forgotten, I was to speak until I saw my name on
the programme, or I should have prepared a larger
diagram to illustrate what I intend to say. Those of
you who are sufficiently near to see this small diagram,
can see that the disease known as influenza, and so
reported to the State Board of Health, is most preva-
lent in February, when it reaches its maximum inten-
(Continv.ed on Page 950)

Jour. M.S.M.S.

>★

• The name is never abbreviated;
other infant food — notwithstanding

and the product is not like any
a confusing similarity of names.

The fat of Similac has a physical and chemical composi-
tion that permits a fat retention comparable to that of
breast milk fat (Holt, Tidwell & Kirk, Acta Pediatrica,
Vol. XVI, 1933) ... In Similac the proteins are rendered
soluble to a point approximating the soluble proteins in
human milk . . . Similac, like breast milk, has a con-
sistently ZERO curd tension . . . The salt balance of
Similac is strikingly like that of human milk (C. W.
Martin, M. D., New York State Journal of Medicine,
Sept. 1, 1932). No other substitute resembles breast milk
in all of these respects.

A powdered, modified
milk product especially
prepared for infant feed-
ing, made from tuber-
culin tested cow’s milk
(casein modified) from
which part of the butter
fat is removed and to
which has been
added lactose, vegetable
oils and cod liver oil
concentrate.

SIMILAR TO
BREAST MILK

MAR DIETETIC LABORATORIES, INC. • COLUMBUS, OHIO

December, 1941

Say you saw it in the Journal of the Michigan State Medical Society

949

HALF A CENTURY AGO

(Continued from Page 948)
sity ; then declines rapidly, and reaches its lowest point
in July, and then rises again until February. It does
that, as a rule, every year. This temperature curve
you see is practically the curve for influenza ; the
lowest temperature, however, is a month earlier than
the time of most influenza. It is apparent, however,
that the temperature alone will not cause influenza.
I have no fault to find with the statement of the author
of the paper that it is a communicable disease, but I
make the point that bacteriologists in searching for_ its
specific cause should not search for a micro-organism
that is uncommon. If influenza is the disease under
consideration, and is a specific disease, the micro-
organism that causes it is present in Michigan in every
month in every year.

In looking up the literature on the subject, I find
that all persons who have reported making micro-
scopical examinations in this disease have found a com-
mon micro-organism in every instance. This is the
common pus-generating micro-organism — the strepto-
coccus pyogenes. Some of the bacteriologists say that
this cannot be the specific cause of the disease, be-
cause it is such a common germ. But, it seems to me,
that if influenza is caused by a micro-organism it must
be caused by one, or more, of the common ones.

There is an element of the atmosphere that is closely
associated with influenza, and that is atmospheric ozone.
It stands even in closer relation to influenza than the
atmospheric temperature does. When the atmospheric
ozone is in excess, the influenza is more than usually
prevalent. At the time of the last epidemic, which
we have just passed through, the meteorological ob-
servers who report to the State Board of Health, re-
ported the presence in the atmosphere of a greater
quantity of ozone than has ever before been reported,
and the influenza has reached a higher point than has
ever before been recorded. The relation which atmos-
pheric ozone sustains to influenza, by months, is ex-
hibited in the diagram which I show you, and which
contains the evidence for Michigan for the twelve
years, 1877-88.

Dr. G. W. Chrouch ; I would like to ask Dr. Baker
if the conditions of influenza have been present every
year for a great number of years. There has pre-
vailed an idea throughout the community at large that
we are only “blessed” with an occasional visitation of
this trouble; that it does not occur every year.

Dr. Baker: I think I stated that the disease was

reported to the State Board of Health as occurring
every February, in fact in every month of every year,
reaching its maximum in . February, and its minimum
point in July. Of course, in some years it is higher
than in others. In February, 1890, it was unusually
prevalent, and still more prevalent during the spring
of 1891.

Dr. Chrouch : I presume every member of the pro-

fession has had more or less to do with what is im-
properly called la grippe. I am an English-speaking
person myself, and prefer to use the English term to
designate the disease under consideration. There is
no difference between what is known as la grippe and
our old English disease, influenza ; and I agree with
the writer of the paper in a great many of the points
he has made. I think, in order to control the general
muscular pains experienced in this disease, that some
preparation of opium is the best. I have tried other
things, but my experience has been that some prepara-
tion of opium would control the muscular pain better
than anything else. I think antipyrine may be used
to control the hyperpyrexia.

As regards the use of mercury as a cathartic and
stimulant to the glandular system, I have not tried it
very much.

I had an unexpected experience last winter. The

influenza resulted in paralysis of the stomach and
bowels, and before I had discovered the paralysis of
the stomach I found I had a distended stomach. It
was filling below the ensiform cartilage to umbilicus.

I took my fingers and worked it back, and it would
stay but a short time. The woman declared that her
stomach was bad. I resorted to nux vomica, and con-
tinued to give the nux until I became alarmed. Shortly
after administering nux vomica a catarrhal cough
came on. On one occasion the woman rolled over to
vomit. I held her head in my hand, it did not go
below the body in general, but there poured out of
her stomach more than half a gallon of liquid. Im-
mediately after, I made an examination for distended
stomach and could not find it. Everything then began
to act. How far the nux vomica I had given had
become absorbed by the paralyzed stomach, I do not
know, but I still believe it had something to do with
the recovery of the case. Very shortly after this oc-
curred, the whole system seemed to be at its maxi-
mum again ; recovery was quite rapid. To control
the hyper-pyrexia, I have relied largely on antifebrin,
sometimes giving capsules of Dover’s powder to relieve
pain and swelling.

Dr. V. C. Vaugh.\n ; I wish to say one or two words
on this subject. I find there is a great deal in a name
after all. I think we have been very unfortunate in

naming this disease. The author of the paper has

called it la grippe. I must say that I can find no

reason for any such name as has been given the
disease.

I saw a statement in an editorial in a leading medi-
cal journal a short time ago that this was a Erench
word, gripper, which means to grasp, to grip. But if
any of you will turn to Hirsch’s famous w'ork on

“The Geographical Distribution of Disease,” you will
find it is not named by this French work at all ; that this
disease appeared in France a number of years ago
simultaneously with a new insect, and the insect was
called la grippe, and as the disease and insect made
their appearance at the same time, it was believed by
the superstitious people of the age that the insects
brought the disease with them, and for that reason
the name was attached to it. There is no reason for
continuing the name.

Now, as to the word influenza, there is no doubt, I
think, as Dr. Baker has remarked, that we have this
disease with us more or less all the time, but there is
a difference between it and the ordinary influenza. We
may call it epidemic, or a pandemic or influenza. The
whole civilized world has been visited a number of -
times by this disease, and there are some interesting :
points known about its spread. In the first place it |
has invariably traveled from east to west ; it makes *
its pandemic excursions at normal regular periods. I
have heard the older physicians speak of its prevalence
during the former Harrisonian campaign (grandfather )
to the present President of the United States).

So far as my observation goes in studying the dis-
ease clinically, it is nothing more or less than the
ordinary influenza which becomes epidemic or pan-
demic.

We meet with many peculiar forms of the disease.
The case of Dr. Chrouch cited is an interesting and
peculiar one. I saw two or three cases accompanied
by complete anesthesia. I suppose these peculiarities
are accounted for from the fact that a great number
of people have been attacked. There are very few
persons who have escaped it. The more prevalent
the disease, the greater the number of persons at- j
tacked, and the greater the number of peculiarities ;
you will find, due to the idiosyncrasies of the patients. ■

There are some things connected with the disease ’
which cannot be reconciled with the idea that it is
due to a specific germ. There are well authenticated »
cases where a ship, for instance, leaving port was not |
(Continued on Page 952)

950

Tour. AI.S.M.S.

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NEW YORK • KANSAS CITY • SAN FRANCISCO • WINDSOR, ONTARIO • SYDNEY, AUSTRALIA

December, 1941

Say you saw it in the Journal of the Michigan State Medical Society

951

HALF A CENTURY AGO

I

(Continued from Pag^e 952)
infected until it had been for weeks at sea. I re-
member one instance — I forget the name of the ship —
where the ship left port and the people were not in-
fected at the time, but had been at sea twelve days
when the disease suddenly appeared and affected all
on board. It is difficult to explain this if we believe
in a specific micro-organism. Bacteriologists, as a
rule, do not believe that micro-organisms are prevalent
at sea.

Culture tubes exposed to sea air for a length of
time have practically remained sterile. There seems
to be some meteorological condition of the atmosphere
which gives special virulence to the germ which is
constantly with us, and so virulent does the germ
become that nearly all are attacked. It seems to me
that is the most rational explanation we can give for
it, taking into consideration the various facts we have
ascertained concerning it.

Of the two names in use, I think the term influenza
the better one. There are twenty or thirty claimants
for the discovery of the germ, but no one has con-
clusively demonstrated his claim. I say it is different
from the ordinary influenza, in that it becomes highly
virulent or epidemic at times. It is on account of
some widely prevalent conditions of the atmosphere,
attacking a large number of inhabitants.

Dr. Chrouch : Have you resorted to any means.

Dr. Baker, to ascertain the condition of the atmos-
phere during these periods?

Dr. Baker: If permitted to speak again, I will say

that I have, and have recorded the results in a paper
which I prepared about a year ago, but which has
not been published. I searched the records of all the
epidemics of which the records were available, and the
most constant meteorological condition that was found
present was an unusual amount of wind, and wind
from an unusual direction. That was true of the
epidemic last year. It began at St. Petersburg; about
two weeks before the outbreak occurred there, the
wind, which at that time of the year is usually from
the southwest, had been from the northeast, sweeping
down from northern Siberia and the Arctic ocean.
At. St. Petersburg the relative humidity of the at-
mosphere was thus greatly lowered below the normal.
This was considered one of the greatest epidemics
they ever had, and it was carefully studied, because
it occurred sufficiently late, and that I was able to
get, from the chief signal officer of the United States,
the exact records of the meteorological conditions at
St. Petersburg.

Now, as regards the recent epidemic in Michigan,
which was the greatest of which we have any record,
we very carefully worked out the meteorological con-
ditions in the State; and in the last quarterly bulletin
of the State Board of Health (that is, the “Pro-
ceedings” of our meeting in April, 1891), the meteor-
logical conditions are carefully stated : The wind

came from an unusual direction, from a colder source
than usual, and the ozone was excessive, especially
in the night time. And I want to say, while I am on
my feet, that the irritating gas in the atmosphere
which is known as ozone, seems to be very easily
destroyed. Our records seem to show that the shut-
ting down of mills, furnace fires, etc., over Saturday
and Sunday, influence it ; and we know that it is
easily broken up, the three atoms of oxygen, of which
ozone is composed, taking their places as ordinary
oxygen. The day ozone is not so regular in its effects
upon our tests ; our record of it does not sustain the
same regularity of relation to diseases of the throat
and air passages as does our record of the night ozone.
The atmospheric conditions during the night are not
interfered with so much by fires and other artificial
measures as during the day. During the last epidemic
the meteorological conditions have been very different
from those that have existed in other years, and suf-
ficiently different to explain, to my mind, the epidemic.

Dr. a. \\*. Alvord: I have been profoundly inter-

ested in the remarks of the gentlemen in relation to
this subject; yet Dr. Baker’s statements are chiefly
a nullity so far as they refer to what the disease
really is. He is not like the practicing physician who
meets with a large number of cases every day, but
he is receiving the reports from hundreds of physi-
cians all over the State, who have certain cards upon
which are printed the names of diseases. For a good
many years I have replied to Dr. Baker’s letters of
enquiry every week. I put down influenza as we had
it, but it was not the influenza we have had the past
year and the year previous. It was nothing like our
present epidemic, even if I accept Dr. Vaughan’s sug-
gestion that an endemic condition is similar to an
epidemic condition.

During the many years that I have practiced, I
would like to know when we had an endemic or
epidemic of influenza that produced the results we
are getting this year from this disease. Some have
been afflicted with ])aralysis and others with marked
neurasthenia, Bright’s disease, and a hundred other
peculiar conditions that we find following it which
I cannot mention at present.

I saw a case, a week ago Sunday night, stricken
down with paralysis, as marked a case of hemiplegia
as I ever saw. Before he was removed to his home
and bed, he had lost not only'^ the use of his legs, but
right arm, and speech left him w-ithin the next two
hours. There was no ability to move his head nor
to open his mouth, and the only set of muscles con-
trolled were those of the left arm. The gentleman
who first saw him was sure there w'as a lesion within
the brain — that this microbe, I do not care what you
call it, affects the nerve centers primarily ; consequently
you can understand how you get marked benefit from
strychnia. A blister was applied on this gentleman’s
neck, he was given a good dose of calomel, and in
three days we had him sitting up, and in a few days
more he was able to walk around. A short time after-
wards he had a similar attack, w'hich lasted three or
four days, and then he was up again.

The conditions have been present from year to year
in its original home. About sixteen months ago it was
transferred across the ocean. I am not surprised at
all that observers should have met with micro-organ-
isms, and that the disease suddenly attacked people on
board a ship, as stated by Dr. Vaughan.

I have not sufficient time to go fully into
this subject, but the remarks have been of
special interest to those who want to know what we
have got — what w^e are dealing wdth. I do not think
any of us know that, and until we do know- w-e are not
going to treat the disease successfully. We may treat
it symptomatically, of course, and we may give acetan-
ilid to control fever. Nux vomica and calomel are
of great benefit in these cases. But what is the cause?
Until we find out the true cause of the disease we are
groping in the dark.

Dr. V. C. Vaughan : Dr. Alvord has said that the

disease this year has been different from previous years,
in that it has been more severe, and the symptoms fol-
lo”dng the disease more variable, and so on.

Hirsch gives an account of an epidemic occurring
in 1847-48. It was called Italian grip ; it was not so
violent in its manifestations and the country was more
thinly settled.

There is another thing : I am sure we are inclined

to attribute everything that occurs now’’ to influenza.
We date everything medically one year or more hack.
Hardly a man comes into our office w-ith a headache
or broken leg but says it is due to the grip. I want
to insist on a point I made before, that the greater the '
number sick with any disease, the greater the variety |
of symptoms, owing to the greater number of idiosyn- ’
(Continued on Page 960)

'952

Tour. M.S.M.S.

A

Liberal preteln content

n An adjusted protein
^ (added gelatin)

D

E

F

G

An adjusted fat
Two added sugars

Added vitamin B complex

4 times as much iron
as cows’ milk

Not less than 400 units
of vitamin D per quart

Rocks along on

Baker’s MODIFIED MILK

from birth through bottle feeding

Once he starts on Baker’s, baby rides along with rarely a
letdown. For Baker’s is rich in essential protein — co-
builder of muscle tissues, blood, bone and teeth. Contains,
in fact, 40% more protein than breast milk — plus comple-
mentary gelatin, an adjusted fat, two added sugars, extra
vitamins and iron.

With all these. Baker’s is highly tolerable to baby’s
digestive system . . . result of its special treatment and
processing.

A powder and liquid modified milk product especially prepared for
infant feeding. Made from tuberculin-tested cows’ milk in which most
of the fat has been replaced by animal, vegetable and cod liver oils,

^together with lactose, dextrose, gelatin, vitamin B complex (wheat
germ extract, fortified with thiamin), and iron ammonium citrate,

U.S.P. Not less than 400 units of vitamin D per quart. Four times as
much iron as in cows’ milk.

A worthy vehicle for easy traveling through infancy,
doctor. Shall we send you complete information about
Baker’s?

THE BAKER LABORATORIES

CLEVELAND, O It i O

West Coast Office: 12S0 Sansome Street, Saa Fra«cisc«

December, 1941

Say you saw it in the Journal of the Michigan State Medical Society

953

READERS’ SERVICE

MARraAGE AFTER FORTY

Success and happiness in married life depend
chiefly upon a well-balanced mutual relation of
husband and wife. After forty this should in-
clude an intimate understanding of the changes
taking place in their natures. Both must real-
ize that married life cannot go on indefinitely on
a diet of romance, but that good comradeship
and mutual respect must exist and thrive con-
tinuously. There must be mutual respect for
each other’s personality, good sense and judg-
ment, entire confidence and frankness when
problems arise and responsibilities present them-
selves. Happiness, contentment, and life abun-
dant will be the result.

The increase of number of divorces and broken
homes in the United States makes another phase
of marriage education imperative. There is a
tendency at the present time to place too much
importance on the physical side of marriage. It
is important, but not all important. Each party
to a marriage should understand that love, good
old fashioned love, not just a passing whim,
must exist. — Harrison Smith Collisi, M.D.,
Grand Rapids. (See page 965.)

SULFATHIAZOL IN EXFOUATIVE
DERMATITIS

A case of wet exfoliative dermatitis associated
with hemolytic Staphylococcus aureus septicemia
in a child of fifteen months is reported. It is
suggested that epidermolysis may be a symptom
of septicemia and that the two children’s dis-
eases showing this phenomena, namely Ritter’s
disease and pemphigus neonatorum, may be
related staphylococcic septicemias. Chemothera-
py now seems to be the treatment of choice.—
Henry K. Baker, M.D., Flint. (See page 969.)

MOVEMENT FOR THE REGISTRATION
OF VITAL STATISTICS

Prior to 1850 the only available statistics of
Michigan consisted of census returns made in
1840 by the federal government. This was the
first census of Michigan as a state. In 1856, a
law was enacted which required the registration
of marriages, but it was carelessly observed.
Following the close of the Civil War many
people claimed pensions and made demands upon
the federal government because of relatives in-
jured or killed during the war. Suffice it to
say, government officials were confronted with
an imperfect record system and could not an-
swer their requests for information concerning
the date of birth of the relative under considera-

tion. As a consequence physicians about the
state and other civic-minded persons became
interested and set about to draft a bill to provide
for the registration of births, deaths, and mar-
riages. The bill was finally approved by the
legislature and became a law on March 27, 1867.
— Earl Kleinschmidt, M.D., Dr.P.H., Chi-
cago. (See page 971.)

PRESACRAL RESECTION FOR THE RELIEF
OF PAIN PRESUMABLY DUE TO A
CONGENITAL UTERINE ANOMALY

After conservative treatment had failed to
relieve a patient’s suffering from dysmenorrhea
associated with uterus didelphis unicolis, opera-
tion was advised. A presacral resection was
performed since the elements of the anomaly
were symmetrical and functioning. Relief of the
patient’s symptoms has been effected, since she
has been free of dysmenorrhea since the opera-
tion.— John C. Scully, M.D., Menominee. (See
page 979.)

THE RELATIONSHIP OF THE ROENTGEN-
OLOGIST TO THE SURGEON

It has been stated that the roentgenologist has
four inseparable friends — the anatomist, pathol-
ogist, internist and surgeon, and one more should
be added — the physiologist.

The physician and surgeon should not shed
his responsibility and expect the roentgenologist
to make the diagnosis for him. The roentgenolo-
gist should be considered in the light of a highly
skilled physician of cooperation and coordination,
one of the important highways to reach the
destination of a workable diagnosis and possible
cure, and not the atlas around which the medi-
cal and surgical diagnosis spins. — Leon M. Bo-
gart, M.D., Flint. (See page 981.)

THE PHYSIOLOGY OF THE NOSE

Many of the nasal physiologic processes are
considered to aid in the evaluation of symptoms
of patients. The efficiency of the nasal mecha-
nism is found to vary in different individuals
and at different ages. The importance of the
pH of nasal mucus is considered as well as the
factors influencing it. The function and drain-
age of nasal mucus is reviewed. Emphasis is
placed on the interrelationship between the nose
and the rest of the body. — Dewey R. Heetderks,
M.D., Grand Rapids. (See page 983.)

THE SUCCESSFUL USE OF SULFANILAMIDE
IN BLACK WATER FEVER

This is a report of a case of black water
fever occurring in a missionary from Africa
while visiting Northern Michigan.

A thirty-six-year-old woman was admitted to
(Continued on Page 956)

954

Jour. M.S.M.S.

Q. Of course, we eat canned vegetables. But just what is
their value in a diet?

A. The nutritional value of fresh vegetables varies some-
what with the type of vegetable. The green, leafy, and
yellow vegetables are among the best sources of pro-
vitamin A. In general, in the amounts usually consumed,
vegetables are valuable sources of vitamin C and mem-
bers of the vitamin B complex. In addition, vegetables
contribute to the body’s needs for iron and other minerals.
Canning retains to a good degree the dietary value of
vegetables and makes a wide variety of vegetables avail-
able all the year round. (i)

American Can Company, 230 Park Avenue, New York, N. Y.

1936. Mass. Agr. Expt. Sta. Bull. No. 338.

1937. Chemistry of Food and Nutrition, Fifth Edition, H. G.
Sherman, MacMillan, N. Y.

1938. Nutrition Abstracts and Reviews 8, 281.

1939. Food and Life Yearbook of Agriculture, U. S. Dept. Agr.,
U. S. Government Printing Office, Washington, D. C.

The Seal of Acceptance denotes that the nutri-
tional statements in this advertisement are accept-
able to the Council on Foods and Nutrition of the
American Medical Association.

December, 1941

Aay you saw it in the Journal of the Michigan State Medical Society

955

READERS’ SERVICE

(Continued from Page 954)

the hospital with temperature of 108.4 degrees,
axillary, complaining of black urine, chills, and
prostration.

In spite of thirteen blood transfusions and the
use of several types of recognized therapy, the
hemoglobinuria continued and red blood count
reached a low point of 610,000 with hemoglobin
of 10 minus. Sulfanilamide was given when
the patient was obviously terminal with dramatic
results and full recovery.

A cholecystostomy was done two months after
the onset with removal of blood pigment stones
from the gall bladder. — Benton A. Holm, M.D.,
Cadillac. (See page 988.)

X-RAYING MILITARY MEN

Experience in the First World War taught us
the importance of discovering tuberculosis
among military men. When the Selective Serv-
ice Act went into effect, the Navy was requiring
a chest roentgenogram for all enlisted and com-
missioned men, and the Army for the commis-
sioned personnel only ; facilities for routine
roentgenography of all men were not at first
available. Among the civilian agencies which
supplemented the efforts of the Army in this
emergency was the Bureau of Tuberculosis of
the New York City Department of Health. A
record of that organization’s experiences is pub-
lished in the Journal of the American Medical
Association from which the following abstracts
are taken.

An order issued October 28, 1940, by the Adjutant
General’s Office of the United States Army made it
possible for civilian organizations to set up a roentgeno-
graphic service for men inducted into the Army. It
provided for payment for x-ray films and for the serv-
ices of civilian roentgenologists (under due control)
until such time as the Army could assemble its equip-
ment and assume full responsibility.

The Bureau of Tuberculosis of the New York City
Department of Health has been engaged in mass roent-
gen-ray surveys of the apparently healthy population
since 1933. These surveys have been accepted as a basic
part of the tuberculosis control program of New York
City and thus interest, based on experience, in provid-
ing a similar service for inductees and members of the
State National Guard was rife. Accordingly, the Bu-
reau’s mass roentgen-ray services which were made
possible through the WPA, were offered to the Sur-
geons of the Second Corps Area prior to the Adju-
tant General’s directive that was issued on October 28,
1940. Financial assistance was received from the tuber-
culosis associations of Queens and the Bronx.

After January 1, 1941, the Army assumed full finan-
cial responsibility for the roentgen-ray service in induc-
tion centers. The Department provided personnel for
the interpretation of films. Since January 15 this serv-
ice has also been taken over by the Army, which has
assigned medical reserve officers qualified in this special
field. The roentgenographing of National Guardsmen
has been entirely at the expense of the Department of
Health. Under existing regulations the Army could not
pay for this service until after induction, and it was
important that rejections be made before induction.

At the outset there were four induction stations.

Since January 1, 1941, all work has been done in two
stations, one in Manhattan and one in Queens.

Those rejected men who were residents of New
York City were given an appointment within the next
two or three days to appear at the Health Department’s
Central Chest Clinic, where a complete study of the
case was made. If this examination proved the original
findings to he of no significance, the local draft board
was so notified.

Rapid roentgenographic service was necessary as the
recruit was supposed to be cleared through all exami-
nations by 2 :30 p.m. of the day he reported at the in-
duction station. With from 60 to 300 men per unit to
be handled daily, even the rapid roll method used in the
routine survey program was inadequate. Consequently
a special type of apparatus was devised. A modification
of the roll paper camera was used in connection with
a specially constructed portable darkroom measuring
8 by 8 feet with the back of the camera integrated
into one side of the darkroom. A signal device was
installed between the roentgen ray technician and the
darkroom. As soon as a film was exposed, the signal
was flashed and the darkroom crew cut off the film
and placed it in the developing bath. The signal was
then reversed indicating that another film was ready to
be exposed. A team of three, consisting of a technician
and two darkroom assistants, were able to operate
faster than one exposure a minute. The films were
processed in large trays and from the fixing bath were
passed out to the physician through a light-proof pass.
After being read, the films were washed in a portable
tank and dried in a special device designed for the
purpose.

Acceptance or rejection was based on Army regula-
tions. Men showing any form of reinfection types of
tuberculosis were rejected because lesions of such types
may become aggravated under conditions of military
service. Primary lesions considered as active or exten-
sive calcifications were likewise cause for rejection.
Other forms of significant pulmonary disease, such as
bronchiectasis, pneumonitis, atelectasis or extensive
pleural changes, were caused for rejection until further
study could determine their importance. Men with ob-
viously abnormal cardiac silhouettes were reported to
the medical examiners for such further study as might
be indicated. Men with nothing more than apical caps,
and those with small well-healed primary lesions were
not rejected.

The group of men examined up to January 15, 1941,
during which the Department of Health was actively
engaged in the program, included 6,609 inductees and
9,541 Guardsmen, a total of 16,150 individuals who
were x-rayed.

Of the inductees, 1.36 per cent were rejected and of
the Guardsmen, 1.21 per cent. About one-third of the
Guardsmen were below the age of twenty-one, while
only about 0.5 per cent of the inductees were below
that age. An all-Negro regiment (National Guard unit)
had the highest mean age in all groups and the highest
rate of rejection, which was almost entirely on the ba-
sis of pulmonary tuberculosis. If the findings in this
unit are subtracted from the totals of all Guard units
a greater difference will be found between Guardsmen
and inductees.

Classification by stages of disease of the seventy men
considered clinically significant shows that 65.7 per cent
were minimal, 32.9 per cent moderately advanced and
1.4 per cent far advanced. Primary lesions indicated
by calcific deposits were found in 6 per cent of the
white men, 8.7 per cent of the Negroes and 7.1 per
cent of the Puerto Ricans.

The group of men examined since January 16 and
through March 31, 1941, totaled 35,210 men. During
that period the Department of Health’s part has been

(Continued on Page 958)

956

Jour. M.S.M.S.

Since you've installed the Ad-
vanced "Series 200", we are pro-
ducing radiographs that are
"tops" in speed, detail, contrast!

The Picker-Waite "Series 200" is
a complete diagnostic x-ray unit
for radiography and fluoroscopy
in any position. Speed, precision
and ease of operation are inher-
ent features of the "Series 200".

THE "SERIES 200" delivers 200 milliamperes over and under
the table.

X-Ray exposures of the lateral pelvis or spine in IV? seconds end
6 foot chest films in l/20th of a second are routine procedure.

intestinal examination.

SINUS AND SKULL WORK is easily achieved— and with complete
comfort to the patient. An adjustable head clamp (optional) facili-
tates positioning and insures immobilization.

December, 1941

Address
City . .

PICKER X-RAY
CORPORATION

300 FOURTH AVENUE
NEW YORK, N.Y.

Gentlemen:

Please send your complete bul-
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vanced "Series 200" Diagnostic
X-Ray Equipment to:

Say you sazv it in the Journal of the Michigan State Medical Society

MISCELLANEOUS

1

(Continued from Page 956)

to reexamine and classify New York City men re-
jected at the induction center. In this time 458 men
have been rejected, 379 of whom have thus far been
cleared at the Health Department Clinic. In forty-
nine, or 12.9 per cent of those reexamined, the cause
for rejection at the induction station was not confirmed
and the man was considered suitable to be accepted in
the Army from the standpoint of his roentgenogram.

A detailed cost analysis of personnel, equipment and
materials necessary to complete this study indicated a
total of $23,614.20. Using this as a basis for computa-
tion, the unit cost to examine each individual by roent-
genogram was $1.47. (The cost of taking a roentgeno-
gram and its interpretation without any further follow-
up was $13,911.20, or 58.8 per cent of the total.) The
unit cost of rejecting a man for military service on the
basis of the total cost was $106.02 for inductees and
$122.37 for Guardsmen.

Spillman has reported that the cost to the federal
government of accepting a person with tuberculosis into
the armed service is $10,000. Thus, in these studies in-
volving 41,819 inductees and 9,541 Guardsmen, or a
total of 41,360 men, 561 persons with chronic pulmo-
nary tuberculosis were rejected, representing an esti-
mated saving to the government of $5,610,000.

Examinations for Tuberculosis by Herbert R. Ed-
wards, M.D., and David Ehrlich, M.D., Jour, of Amer.
Med. Assn., July 5, 1941.

FOURTH ANNUAL FORUM ON ALLERGY

The Fourth Annual Eorum on Allergy will be held
this year in the Statler Hotel, Detroit, Michigan, on
Saturday and Sunday, January 10 and 11, 1942. On
the Friday preceding there will be clinics at the
University Hospital in Ann Arbor, Michigan, conducted
by Dr. John M. Sheldon and the staff. All reputable
physicians are most welcome at The Forum where they
are offered an opportunity to bring themselves up to
date in this rapidly advancing branch of medicine,
through two days of intensive postgraduate instruc-
tion; for instance, the twenty study groups, any four
of which are available to each attending physician, will
be given continuity in that one series deals with Oto-
laryngology, Ophthalmology, Pediatrics, Internal Medi-
cine, and Dermatology — ^each running consecutively.

Attention is called to the fact that during these two
days almost every type of instructional method will
be employed by the forty-six physicians appearing on
the program.

Special lectures by outstanding authorities ; symposia
followed by a twenty-minute question and answer pe-
riod ; presentation of patients and a free discussion of
their management ; charts and educational exhibits ;
motion pictures and colored transparencies ; the re-
sults of research; and, finally, an “Infoimation on
Allergy, Please?” where any question which has not
been answered in the two days may be asked of com-
petent authorities.

The second award of The Forum’s Gold. Medal for
outstanding contributions to clinical allergy will be
made this year to W. W. Duke, M.D., of Kansas City,
Missouri, who well may be called “the father’’ of this
subject.

Men from Michigan taking part in the program are :
Samuel Levin, Detroit; Franz Blumenthal, Detroit;
Frank Menagh, Detroit ; George L. Waldbott, Detroit ;
Harvey Johnston, Ann Arbor; John M. Sheldon, Ann
Arbor; Stanley Insley, Detroit; Meryl Fenton, Detroit,
and Meyer Ascher, Detroit.

Physicians desiring a program or further informa-
tion may address the Director, Jonathan Forman, M.D.,
956 Bryden Road, Columbus, Ohio.

CREDIT IS DUE

The following members of the ^Michigan State Medi-
cal Society registered at the 76th Annual Convention
and exhibition held in Grand Rapids, September 16, 17,
18 and 19, 1941. The list of those registering on Tues-
day, September 16, follows :

George T. Aitken, Grand Rapids; J. K. Altland, Hastings;
W. H. Alexander, Iron Mountain; Ralph V. Allen, Grand
Rapids; Harvey M. Andre, Grand Rapids; J. H. Andries, De-
troit.

Milner S. Ballard, Grand Rapids; Wm. R. Ballard, Bay City;
W. D. Barrett, Detroit; Gaylord S. Bates, Detroit; Martin
Batts, Jr., Grand Rapids; T. I. Bauer, Lansing; M. G. Becker,
Edmore; VV. Clarence Beets, Grand Rapids; H. M. Best, Lapeer;
W. L. Bird, Greenville; H. M. Blackburn, Grand Rapids; Frank
A. Boet, Grand Rapids; Walter H. Boughner, Algonac; Donald

R. Brasie, Flint; Horatio A. Brown, Jackson; James D. Bruce,
Ann Arbor; C. F. Brunk, Detroit; Jacob H. Burley, Port
Huron; Volney N. Butler, Detroit.

A. L. Gallery, Port Huron; A. M. Campbell, Grand Rapids;
A. E. Catherwood, Detroit; L. G. Christian, Lansing; Harry

L. Clark, Detroit; Robert W. Claytor, Grand Rapids; Harrison

S. Collisi, Grand Rapids; B. L. Connolly, Detroit; T. S. Conover,
Flint; Henry Cook, Flint; W. B. Cooksey, Detroit; C. A. Cooper,
Hancock; Burton R. Corbus, Grand Rapids; Wm. J. Cosgrove,
Grand Rapids; George J. Curry, Flint.

E. N. D’Alcorn, Muskegon; Ernest W. Dales, Grand Rapids;
Milton A. Darling, Detroit; David B. Davis, Grand Rapids;
Luther W. Day, Hillsdale; Dean C. Denman, Monroe; Isla G.
DePree, Grand Rapids; J. DePree, Grand Rapids; C. F.
DeVries, Lansing; H. F. Dibble, Detroit; C. A. Dickinson,
Wayland; Douglas Donald, Detroit; James C. Droste, Grand
Rapids; Fred Drummond, Kawkawlin; C. E. Dutchess, Detroit.

Charles E. Farber, Grand Rapids; Lynn A. Ferguson, Grand
Rapids; Gordon F. Fisher, Hastings; E. O. Foss, Muskegon;
G. H. Frace, St. Johns; H. A. Furlong, Lansing.

Harold H. Gay, Midland; L. O. Geib, Detroit; Louis W. Gerst-
ner, Kalamazoo; Orla H. Gillett, Grand Rapids; Frank A.
Grawn, Traverse City; I. W. Greene, Owosso; T. K. Gruber,
Eloise; A. B. Gwinn, Hastings.

A. T. Hafford, Albion; Don V. Hargrave, I^ton Rapids;

F. W. Hartman, Detroit; C. K. Hasley, Detroit; C. L. Hess,
Bay City; L. J. Hirschman, Detroit; T. E. Hoffman, Vassar;

M. H. Hoffmann, Eloise; William A. Hyland, Grand Rapids.
C. F. Ingersoll, Grand Rapids; S. D. Insley, Detroit.

R. C. Jamieson, Detroit; L. J. Johnson, Ann Arbor.

J. A. Kasper, Detroit; Thos. R. Kemmer, Grand Rapids; C. S.
Kennedy, Detroit; C. R. Keyport, Grayling; M. R. Kinde, Bat-
tle Creek; D. K. Kitchen, Grosse Pte. Pk. ; P. W. Kniskern,
Grand Rapids; Leo O. Knoll, Ann Arbor; H. J. Kullman, De-
troit.

Bertil T. Larson, Pontiac; P. L. Ledwidge, Detroit; C. E.
Lemmon, Detroit; Robert T. Lossman, Traverse City; S. L.
Loupee, Dowagiac; Henry A. Luce, Detroit.

Alexander M. Martin, Grand Rapids; Robert J. Mason, Bir-
mingham; S. C. Mason, Menominee; Fred G. Mayne, Cheboy-
gan; L. M. McBryde; S. S. Marie; Allan McDonald, Detroit;
Maurice McGarvey, Blissfield; R. M. McKean, Detroit; C. M.
Mercer, Battle Creek; J. Duane Miller, Grand Rapids; John J.
Miller, Marne; Frederick B. Miner, Flint; H. C. Mitchell, Grand
Rapids; L. J. Morand, Detroit; H. Allen Moyer, Lansing; Dean
W. Myers, Ann Arbor.

W. E. Nesbitt, Alpena; H. V. Norgaard, Marlette; F. O. Novy,
Saginaw; R. L. Novy, Detroit.

C. W. Oakes, Harbor Beach; E. A. Oakes, Manistee; D. J.
O’Brien, Lapeer; J. J. O’Meara, Jackson; E. A. Osius, Detroit.
C. Allen Payne, Grand Rapids; R. C. Peckham, Gaylord;

G. C. Penberthy, Detroit; Ralph A. Perkins, Detroit; Henry E.
Perry, Newberry; Ralph H. Pino, Detroit; Horace Wray Porter,
Jackson; Anthony M. Putra, Detroit.

Carl S. Ratigan, Detroit; Frank E. Reeder, Flint; Wm. S.
Reveno, Detroit; H. H. Riecker, Ann Arbor.

Gilbert B. Saltonstall, Charlevoix; E. W. Schnoor, Grand
Rapids; Donald M. Schuitema, Grand Rapids; H. T. Sethney,
Menominee; Bert H. Shepard, Lowell; C. E. Simpson, Detroit;
William J. Slasor, Ann Arbor; C. C. Slemmons, Grand Rapids;
W. Joe Smith, Cadillac; Carl F. Snapp, Grand Rapids; Geo. H.
Southwick, Grand Rapids; E. D. Spalding, Detroit; R. A.
Springer, Centerville; Wallace H. Steffensen, Grand Rapids;
A. E. Stickley, Coopersville ; Wm. F. Strong, Ontonagon; O. D.
Stryker, Fremont.

Athol B. Thompson, Grand Rapids; Marcus B. Tidey, Grand
Rapids; Don W. Thorup, Benton Harbor; Franklin H. Top,
Detroit; Wm. R. Torgerson, Grand Rapids.

C. F. Vale, Detroit; Harvard J. VanBelois, Grand Rapids;
R. S. VanBree, Grand Rapids; V. Vandeventer, Ishpeming;
Harold E, Veldman, Grand Rapids.

M. O. Wade, Coldwater; J. J. Walch, Escanaba; R. 'V'.
Walker, Detroit; Arch Walls, Detroit; A. V. Wenger, Grand
Rap'ds; John A. Wessinger, Ann Arbor; D. Bruce Wiley, Utica;
E. B. Witwer, Detroit; Merle Wood, Hart; Arthur R. Wood-
burne. Grand Rapids.

Gordon Yeo, Big Rapids; W. R. Young, Lawton.

The list of those attending on Wednesday, Thursday
and Friday will appear in subsequent issues of The
Journal.

958

Jour. M.S.M.S.

KOROMEX DIAPHRAGM

KOROMEX

TRIP-RELEASE INTRODUCER

TIP TURNS
ON SWIVEL

Hollai^-Rantos

Ucrmpa/ny, unc.

551 Fifth Avenue

New York, N.Y.

December, 1941

Say you saw it in the Jourml of the Michigan State Medical Society

959

COUNTY MEDICAL SOCIETY MEETIINGS

Bay-Arenac-Josco — Wednesday, October 22, 1941 — Bay
City — Subject: “Shock Therapy for the Mentally

Sick.”

Wednesday, November 12, 1941 — Bay City — Speaker :
H. C. Fields, M.D., Ann Arbor — Subject: “Vita-

mins.”

Berrien — Thursday, November 13, 1941 — Benton Har-
bor— Speaker : Chauncey C. Maher, M.D., Chicago —
Subject: “Acute and Chronic Nephritis.”

Calhoun — Tuesday, ^November 4, 1941- — Battle Creek —
Speaker: Robe, rC* Bruce Malcolm, M.D., Chicago —
Subject: “Tumors of the Large Bowel.”

Dickinson-Iron — Thursday, November 6, 1941 — Iron

Mountain— Speaker : John Claridge, M.D., Chicago.

Hillsdale — Tuesday, November 4, 1941 — Hillsdale —

Speakers : M. R. Kinde, M.D., Battle Creek and J.

P. Gray, M.D., Hillsdale.

Ingham — Tuesday, October 21, 1941 — Lansing — Speak-
er : Charles F. McKhann, M.D., Ann Arbor — Sub-

ject: “Convulsions in Infancy and Childhood.”
Tuesday, November 18, 1941 — Lansing — Speakers: R.
H. Denham, M.D., Grand Rapids — Subject: “Infec-

tions of the Hand.”

lonia-Montcalni — Tuesday, November 11, 1941 — Grand
Rapids — Met with the other Societies of the Fifth
Councilor District.

Oakland — Wednesday, October 1, 1941 — Rotunda Inn —
Speaker: Prof. N. B. Lewis, Ann Arbor — Subject:

“What About Vitamins?”

St. Clair — Tuesday, October 28, 1941 — Port Huron —
Speaker : Grover C. Penberthy, M.D., Detroit — Sub-
ject: “Treatment of Appendicitis.”

Tuesday, November 11, 1941 — Port Huron — Speaker:
S. W. Insley, M.D., Detroit — Subject : “Office Prac-

tice of Allergy by the General Practitioner.”

IVashtenaw — Tuesday, November 11, 1941 — Ann Arbor
— 14th District Meeting.

IVayne — Monday, December 1, 1941- — Detroit — General
Meeting. “Certain Problems Associated with the
Treatment of Goiter” by George Crile, Jr., M.D.,
Cleveland. ,

Monday, December 8, 1941 — Detroit — Medical Meet-
ing— “The Use and Abuse of Barbiturates” — Speaker :
Wm. D. McNally, M.D., Chicago.

Monday, December 15, 1941 — Detroit — General Prac-
tice Meeting — Joint session with the Detroit Pediatric
Society.

West Side (Wayne) — Wednesday, November 26, 1941
— Ninth Annual Clinic — Speakers: H. Balberor, M.D.,
H. J. Walder, M.D., S. D. Jacobson, M.D., C. J.
Smyth, M.D., H. N. Horan, M.D., M. K. Newman,
M.D., D. C. Somers, M.D., F. A. Weiser, M.D.,
G. B. Myers, M.D., F. Margolis, M.D., and Muir
Clapper, M.D. The Clinic was conducted by S. E.
Gould, M.D., at Seymour Hospital, Eloise.

* * *

COUNCIL AND COMMITTEE MEETINGS

1. Wednesday, November 12, 1941 — Industrial Health
Committee — Olds Hotel, Lansing — 6:30 p.m.

2. Thursday, November 13, 1941 — Executive Committee
of The Council — Olds Hotel, Lansing- — 12 :00 noon.

3. Monday, November 17, 1941 — Prelicensure Medical
Education Committee — Olds Hotel, Lansing — 6:30
p.m.

4. Sunday, November 30, 1941 — Committee on Scientific
Work — Olds Hotel, Lansing — 3 p.m.

NEW COUNTY SOCIETY OFnCERS
Clinton

W. B. McWilliams, M.D., Maple Rapids, President.
Arthur C. Henthorn, M.D., St. Johns, Vice President.
T. Y. Ho, M.D., St. Johns, Secretary-Treasurer
G H. Frace, M.D., St. Johns, Delegate.

D. W. Hart, M.D., St. Johns, Alternate Delegate.

Genesee

Donald R. Wright, M.D., Flint, President.

Walter Z. Rundles, M.D., Flint, President-Elect.

John S. Wyman, M.D., Flint, Secretary.

Donald L. Bishop, M.D., Flint, Treasurer.

Herbert Randall, M.D., Flint, Medico-Legal Officer.
D. R. Brasie, M.D., Flint, Delegate.

Frank E. Reeder, M.D., Flint, Delegate.

Henry Cook, M.D., Flint, Delegate.

Robert Scott, M.D., Flint, Delegate.

A. Dale Kirk, M.D., Flint, Alternate Delegate.

T. S. Conover, M.D., Flint, Alternate Delegate.
Frank Johnson, M.D., Flint, Alternate.

Mrs. Sara M. Burgess, Flint, Executive Secretary.

MEMBERS OF MEDICAL BOARDS

Members of Michigan State Board of Registration

in Medicine

Term Expires

J. Earl McIntyre, M.D., Lansing Expired in 1940

C. R. Keyport, M.D., Grayling 9/30/43

Elmer VV. Schnoor, M.D., Grand Rapids 9/30/45

Luther Peck, M.D., Plymouth 9/30/45

Francis O’Donnell, M.D., Alpena 9/30/43

Ruby R. Goldstone, M.D., Detroit 9/30/43

Andrew C. Roche, M.D., Calumet 9/30/43

Eugene S. Thornton, M.D., Muskegon 9/30/45

Harold L. Morris, M.D., Detroit 9/30/45

Charles W. Balser, M.D., Detroit 9/30/45

Members of Advisory Council of Health
H. Allen Moyer, M.D., Commissioner, Charlotte.... 6/30/43

Henry F. Vaughan, Dr.P.H., Ann Arbor 6/30/43

O. D. Stryker, M.D., Fremont 6/30/43

John Galbo, D.D.S., Detroit... 6/30/45

Harold E. Wisner, M.D., Detroit 6/30/47

Roy C. Perkins, M.D., Bay City 6/30/47

Members of Board of Examiners in the Basic Sci-
ences

Paul L. Rice, Alma 10/29/43

Prof. A. M. Chickering, Albion 10/29/45

Warren O. Nelson, Detroit 10/29/45

Orin E. Madison, Detroit 10/29/47

Henry F. Vaughan, Ann Arbor 10/29/47

HALF A CENTURY AGO

(Continued from Page 952)

crasies that enter into the methods of living, general
construction, build of the system, etc.

Dr. Alvord : I think the doctor’s remarks have a

good deal of force, in that the tendency of the tirnes
is to attribute everything to this disease. I would like
to have the doctor feel that we fellows who are out
in the fields practicing medicine, are oftentimes quite
as particular as college men are in differentiating cases.
The fact is, I do not know much about this disease, and
I wanted to stir up the learned men as much as pos-
sible, to obtain all they know for the benefit of the
Section, but I do not believe they have arrived at any
more conclusions than I have. I was only trying to feel
their pulse on the subject.

960

Jour. M.S.M.S.

T>i£ journal

of the Michigan State Medical Society

Issued Monthly Under the Direction of the Council
Volume 40 December, 1941 Number 12

Marriage After Forty*

By Harrison S. Collisi, M.D., F.A.C.S.

Grand Rapids, Michigan

Harrison Smith Collisi, M.D.

M.D., University of Michigan, 1912. Chief
of Division of Obstetrics and Gynecology,
B'utterworth Hospital; Courtesy Staff, Obstet-
rics and Gynecology^ Blodgett Memorial Hos-
pital; Special Visiting Staff, Obstetrics and
Gynecology, St. Mary’s Hospital; _ Fellow,
American College of Surgeons; Diplomate,
American Board of Obstetrics and Gynecology;

Member, Michigan Society of Obstetricians
and Gynecologists (Detroit) ; Member, Michi-
gan State Medical Society.

■ Man, in primitive life, chose a mate because of
his instinctive urge to reproduce his kind. Love
did not become an important factor in his life
until civilization had developed his understanding
of law and order, and had taught him that his
innate right to possess a woman was based upon
moral, religious and sociological principles that
exist today as the most adamant of our whole
fundamental structure.

As civilization advanced divorce and re-
marriage became known. Statistics show that
successful marriages are those that go beyond
the age of forty. But after forty is the time
when the most serious crashes in matrimonial life
occur. By this time children have been brought
into the world, the family has grown, the eco-
nomic foundation has been established and the
physical attraction between man and wife has
reached its zenith. A break in marriage at this
time would be a most serious incident in the life
cycle of the married couple.

Most of us look at marriage through a misty
haze of poetical and romantic language. We
expect it to be the fulfillment of desire, joy, love

*Delivered at the annual meeting of the Woman’s Auxiliary
to the M.S.M.S., Detroit, Michigan, September 21, 1938.

and life. The foundation of happiness and of
health is made in the first months of marriage,
and the years that follow are colored by those
early days — most momentous to the man and
highly fascinating to the woman. When tolera-
tion supplants cooperation love dies and marriage
is little more than misapprehension, disillusion-
ment and alienation.

There is a time in the lives of most married
people when a domestic disagreement may occur.
It may be only a trivial tiff which readily corrects
itself, or it may take on serious proportions
which threaten to disrupt what has heretofore
been a happy union. Several factors are con-
cerned— moral, economic, jealousy, outside inter-
ference, sexual maladjustment, and a variety of
other causes.

The duration of marriage and the presence of
children are important considerations in marital
conflicts. In marriages of short duration a large
percentage of disagreements arise from failure
of the partners to understand each other. TLe
marriage is not old enough for each to have
become thoroughly acquainted with the other.

After forty, when married couples are expected
to have mature marital judgment another factor
comes into their lives. At this time Mother
Nature begins to play a trick on man and woman.
An era is entered when certain physical and
emotional changes take place. The success and
happiness of married people after forty depend
chiefly upon an intimate knowledge and an under-
standing of these changes.

So insidiously does this change creep upon the
man that the woman may not recognize it and
therefore fails to understand his changing nature.
In the case of the wife the signs of the change
are more abrupt and noticeable, although the
degree in which they occur may vary.

In order to understand more thoroughly the
changing natures of man and woman after forty.

December, 1941

965

MARRIAGE AFTER FORTY— COLLISI

we should know something of their normal
natures in earlier life.

Nature of Man

Ages ago, man lived in trees, caves and as a
nomad following his flocks. Today he has de-
veloped new physical structures, new ways of
living and emotional responses that are represent-
ative of the cumulative experiences of mankind.
But it is only in the last half century that he has
seriously begun the study of his emotional life.

Man’s instinct of reproduction, of which all
normal men are aware, is foremost in his life.
Quite often, it exists independent of love with
its associated feelings of sympathy, under-
standing, and companionship. These instincts
and feelings, in a normal healthy man, may not
be centered on the same woman. A man may
love a woman and not be physically attracted
to her; or he may have a strong physical at-
traction to another woman whom he does not
love.

A marriage in which the man does not have
love and strong physical attraction toward his
wife is usually unsuccessful. If he does not
have this attraction before he marries her, he
is not likely to acquire it afterward and such a
marriage is almost certain to be a failure. This
instinct in man is natural and women should
realize the importance of treating its first
manifestations with broad understanding.

The sex coefficient varies in man. Naturally,
he is agressive, impatient, quickly aroused and at
times misunderstanding and inconsiderate in his
sexual demands. He may lack control of his
sexual urges, be unreasonable, and his sexual
ethics may even be crude and repulsive.

Nature of Woman

Before the dawn of civilization, woman had no
other purpose on this earth except to be the mate
of man and to bear his offspring. Because of the
long period of gestation and dependence of the
child upon its mother, woman was incapacitated
and needed protection of man if she and her
young were to survive. As a result of her de-
pendence on man, she fell under his domination
to such an extent that her primary sexual im-
pulses were obscured. But when social behavior
became known, her life was controlled by man-

ners, morals and customs. She contended for
release from male domination and after centuries,
man conceded to her demands.

Accepting the scriptural span of life as three
score and ten years, a woman’s life may be
divided into three distinct periods : the period of
immaturity, or the “Age of Innocence” ; the
period of sexual activity, which is biologically
the most important but not often the happiest
portion of a woman’s existence ; and the period
of menopausal life, when the organs of reproduc-
tion cease their activity and the ability to bear
children comes to an end.

In the period of sexual activity, woman’s sexual
needs and responses are not identical with man’s.
Mating comes to her as a response to a general
harmonious feeling of well-being, rather than as
a result of a specific erotic stimulation. IMan
cannot expect to find in the normal woman the
same frequent, intense urge that he experiences.
Since monogamy is the standard set by our
social structure, he must recognize sexual differ-
ences. He must learn that her sex life is a more
diffuse part of her nature. Sexual desire in
woman is largely mental and to a great extent
stirred by the feeling of love for her husband.

Man and Woman During the Climacterium

We hear much of the “Dangerous Forties,”
the period of change in the lives of man and
woman, or what is termed scientifically the
climacterium. That such a period exists in the
life of woman has long been known, but Maranon
was the first to point out the evidence of a male
climacterium, the symptoms of which closely
parallel the non-menstrual manifestations in
woman.

The climacterium has a different effect upon
each physically, but in both there is a state of
mental unrest, emotionalism, tendency to gloom-
iness, apprehensiveness, irritability, and even in-
sanity. Suicide is not infrequent, particularly in
males. There is a change of sex inclinations
usually shown by a decline in sex activity, and it
may be lacking entirely. In some cases it becomes
excessive and leads to social complications.

In women, seventy-five per cent suffer from
distressing symptoms during the climacterium.
In addition to the abrupt cessation of menstrua-
tion certain nervous disturbances occur. The
most frequent of these consist of irritable temper,
excitability, hysteria, fatigue, insomnia, depres-

966

Jour. M.S.TvI.S.

MARRIAGE AFTER FORTY— COLLI SI

sion and crying, fear and anxiety, forgetfulness
and loss of memory. The mental state should be
carefully observed, as melancholia and other
forms of insanity may develop at this period in
woman with a hereditary taint or neurotic tenden-
cy. Other symptoms such as flushes and chills,
palpitation and rapid heart, difficult respiration,
neuralgia in various parts of the body, burning
sensations, headaches, and frigidity may also be
present. Occasionally, the sexual appetite in-
creases and some women with little previous
desire suddenly develop a passionate nature, but
usually sexual reserve is an outstanding feature.

In man, the appearance and symptoms of the
change come gradually and insidiously. There
is nervous imbalance, his judgment may be
affected and he is easily led from the straight
and narrow path o£ discretion. His whole
endocrine system is affected. He has inherited
the nature of his cave-man ancestors and may
fail to understand the trick that Nature is
playing. Sometimes he regards his decline in
sexual function as cause for a shift in his
sexual attentions, so he lets himself be at-
tracted to other fields of indulgence — drinking,
gambling, women. At once he arouses the ire
of his mate, quarrels ensue, and usually the
final result is — mutiny in the home.

A wife usually re-acts to her husband’s “change
of life” by becoming suspicious of him, loses
confidence in him, is antagonistic and misunder-
standing. She does not understand his sudden
loss of interest in her and is surprised that she
is neglected when her sexual proclivities are no
longer luring to her mate as they were in earlier
life. She may become jealous and accuse him of
infidelity. Quite often a wife berates her husband
publicly and privately. She believes she has mar-
ried a man of her own nature and does not realize
that he is physically and emotionally different.
Some women are keenly analytical of man’s
genetic behavior and know more about their
husbands and sons than they do about their
daughters and themselves. They are usually in-
terested in such subjects as sane sex living, sex
ethics, sex freedom, birth control and maternal
health, and seek enlightenment by reading, at-
tending lectures and consulting the family physi-
cian.

On the other hand a man may become suspi-

cious of those with whom he is working. He
feels that others are holding him down and are
getting the better of him. He may even picture
the woman with whom he lives as a mere object
for his sexual gratification and have no love for
her. This situation may terminate ultimately, and
usually does, in domestic disaster.

Woman After Forty

The menopause connects two eventful periods
in a woman’s life, the span of childbearing and
the later years of greatest intellectual vigor. The
gloomy picture of “change of life” painted by the
laity is thoroughly unjustified. It has been said
that from fifteen to forty are a woman’s richest
years — ^}^ears of vitality, courage, accomplishment,
emotion, charm. Yet there is a time in her life
after forty at which she may be endowed with
frank happiness and a healthy vigor of mind and
body heretofore unsurpassed. For many women
of the upper social classes, life really begins at
forty. At that time they undergo a temperamental
renaissance. Doctor Graves, the eminent gyne-
cologist, aptly puts it : “Relieved of the anxieties
of childbearing and the annoyances of menstrual
function, and reconciled to the cosmetic altera-
tions of old age, they acquire a mental and phys-
ical vitality never before experienced, and enjoy
for a decade or two the best years of their life.”

Some women past the climacterium, especially
those who have never borne children and those of
the maiden class, may acquire an attractiveness
that they never before possessed.

Intellectual attainments may become prom-
inent. Often, a woman enters a new and calm
enjoyment of intellectual occupations, becomes
an important factor in society and finds more
time for her family and home. To offset her
decline in sex life, she turns to writing, art,
politics, and many other worth-while endeav-
ors. History tells us that many women have be-
come nationally famous in various fields. Ex-
amples of such women may be called to mem-
ory and are observed every day in civic life.

The woman whose life has been spent in
mere pleasure-seeking, who has neglected the
cultivation of mind and heart, and who knows
nothing of the peace and poise found in the
comforting assurance of a Christian faith, finds
life wearisome and lonely. When she dis-
covers that she no longer attracts the opposite

December, 1941

967

MARRIAGE AFTER FORTY— COLLIST

sex and is unable to acquire new interests, she
becomes bitter, repressed, misunderstood, and
drifts on into an unhappy, retrospective old
age.

Upon the' mental horizon of every woman, as
she approaches the forties, there looms this pend-
ing crisis through which she must inevitably
pass. In the minds of many, tradition has in-
stilled a fear that when the change supervenes
the bloom of life will fade and the burdens of
age will be assumed. She may sadly refer to her
more youthful attractions, in the words, “When
I was a woman.” But when a woman reaches
maturity she should not be impressed with the
notion that her life is limited by her reproductive
activity and by her reciprocal relations with the
opposite sex, and that after the cessation of this
function there will remain little of interest for her
during the remainder of her mundane existence
other than to train her daughters to occupy a
similar field of procreation activity. A broader
and truer view is that life is a school in the
vestibule of eternity leading to larger spheres of
activity, responsibility and enjoyment, and each
age is important and brings its own opportunities
for spiritual development and achievement.

The woman after forty should realize that her
life is a treasury filled with the wealth of ex-
perience that she has accumulated from child-
hood to maturity. Childhood, the age of acquisi-
tiveness, discipline and untainted joys ; early
maturity, with its happy relationships and fascin-
ating revelations of conjugal life ; home, husband,
children — each have contributed a most valuable
share. And now, maturity, merging invisibly as it
does, into old age and the more abundant, un-
trammeled life beyond, places the crown of
experience and authority upon her worthy head.
Many of our noblest citizens, most devoted to
the common welfare, are women at this period
of life. They are living in a period of rejuve-
nescence— “The gauge of their age is not years,
but vital force.”

Until a few years ago the medical profession
had little to offer the woman suffering from the
menopausal syndrome. Treatment consisted
chiefly of sedatives and psychotherapy, but today
the progress of scientific medicine has made it
possible to relieve the troublesome symptoms of
the climacterium and to do much to make a
woman’s life enjoyable to her. The woman who

is unable to adjust herself to the conditions of
life under which she is living frequently asks
herself the question, “Why was I born a wom-
an?” and then often finds escape from her emo-
tional difficulties in illness.

The profound economic and social changes
that have occurred in the lives of most American
women and those of other civilized countries
during the last fifty years have directed new
interest to the health problems which concern
women particularly. The economic independence
of woman plays an important part in her health.
In order to keep herself physically fit so that she
may compete with man in the world today, a
woman should pay particular attention to her
physical and mental health. The responsibilit}’
for domestic management involves a much greater
output of physical energy than that to which a
woman has been accustomed.

One is led to believe that the health of a
married woman is more precarious than that of
her unmarried sister, but it appears that the
reverse is actually the case. The biologic norm
is more closely fulfilled by marriage which in-
creases the mental and bodily well-being of a
woman, provided the simple rules of health are
followed. Goodwin in the “Health of the Mar-
ried Woman” states that when a woman marries
there are four main directions in which her life
is altered ;

1. Responsibility for domestic management.

2. Companionate life.

3. Sex life.

4. Reproductive life.

The problem of companionate existence for
a woman who marries is likely to be more
difficult than for a man. This is largely be-
cause most men have always been to some
extent dependent on female supervision, while
a woman generally develops a philosophy of
independence to the opposite sex.

Upon the gynecologist today rests the dif-
ficult task of guiding a woman through this
most trying period of her life to the end that
she may safely reach the quiet waters and
serene environment of a happy mature age.
“This channel is beset with treacherous rocks
and shoals upon which the ship of health of
woman may only too readily be wrecked or
stranded.”

968

Jour. M.S.M.S.

EXFOLIATIVE DERMATITIS— BAKER

Conclusion

Success and happiness in married life depend
chiefly upon a well-balanced mutual relation of
husband and wife. After forty this should in-
clude an intimate understanding of the changes
taking place in their natures. Both must realize
that married life cannot go on indefinitely on a
diet of romance, but that good comradeship and
mutual respect must exist and thrive continuously.
There must be mutual respect for each other’s
personality, good sense and judgment, entire
confidence and frankness when problems arise
and responsibilities present themselves. Hap-
piness, contentment, and life abundant will be
the result.

The family of today should control its social
behavior by a code of irreproachable manners,
morals and customs. It should be a one-wife,
one-husband family for man is no more polyg-
amous than woman is polyandrous. Polygamy
and polyandry are innovations in human society as
are infanticide, prostitution, celibacy, homosexual-
ity, autoeroticism, and other sex psychoses, which
are “as barren as vestal virgins and biologically as
useless.”

Modernistic marriage has come into existence
during the last few years. Our experience with
it is too inadequate to really accept it as a part
of our present social structure. It may be likened
to a mirage — a vision of sensuous splendor which
appeals at first but soon fades into an unsuc-
cessful experiment.

The increase of number of divorces and broken
homes in the United States makes another phase
of marriage education imperative. There is a
tendency at the present time to place too much
importance on the physical side of marriage. It
is important, but not all important. Each party
to a marriage should understand that love, good
old fashioned love, not just a passing whim,
must exist.

“Life is not a stagnant pool, it is a flowing
river carrying the human race to higher stand-
ards, to newer and better things, to more complete
understanding of our environment and to mar-
velous revelations of the potentialities within
ourselves.”

=r-r=[V|SMS

Sulfathiazole in Exfoliative
Dermatitis

By Henry K. Baker, M.D.

Flint, Michigan

Henry K. Baker, M.D.

M.D., N orthwestern University, 1935. Mem-
ber, Genesee Co'u.nty Medical Society; Mem-
ber, Michigan State Medical Society.

■The purpose of this paper is to record an-
other® case of recovery in massive exfoliative
dermatitis treated with sulfapyridine, and, par-
ticularly, to suggest that massive wet exfoliative
dermatitis, or “epidermolysis,” is a symptom of
a severe toxic or septic state, and that what have
been previously felt to be clinical entities, namely
neonatal pemphigus and Ritter’s disease, may
occur at ages other than neonatal infancy, and
may possibly not be entities at all but merely
types of reaction to a septicemia, bacteremia, or
localized staphylococcic infection.

Ritter von Rittershain, in 1870, first described
an acute disease of the first month (usually first
week) of life, associated with massive epider-
molysis, septic course and usually fatal outcome.
He reported some 297 cases in ten years. Since
then fewer and scantier reports are found and,
although Ritter himself believed this disease a
pyogenic infection, the literature is confused re-
garding the cause and also regarding its relation-
ship to pemphigus neonatorum, which, in chil-
dren at least, is generally agreed to be a staphylo-
coccus skin infection.

Hart^ described two institutional epidemics of
pemphigus neonatorum and Daveo^ one, in which
the skin manifestations and the clinical courses
varied from mild illness with a few discrete bullae
to massive exfoliative dermatitis with septic
course and termination indistinguishable from
Ritter’s disease. Daveo states that he feels that
Ritter’s disease is merely a fulminating and more
massive type of pemphigus neonatorum.

The pathology of Ritter’s (Cailliau,^ Kendall®)
is not different from that found in fatal pem-
phigus cases, only the rapidity of the clinical
course and extent of dermolysis seem to vary.

While Raschkes’’ reports a case of an infant
bom with established Ritter’s disease, most cases,
as for pemphigus neonatorum, start in the first
week and recover or die in the second or third.

December, 1941

969

EXFOLIATIVE DERMATITIS— BAKER

though one of Ritter’s own cases occurred in the
seventh month of life.

It is because of this reported neonatal inci-
dence that we offer the present case with some
hesitation and explanation.

Case Report

The patient, L. A. B., was a white male, aged fifteen
months, weight 22 pounds. Normal at birth and of 7
pounds weight, he was the fourth male offspring. The
family history was normal except that an older sibling
had died of erysipelas before the birth of the patient.

This patient was well until February 5, 1941, when
he broke out with measles, acquired from an older
brother. He was up and about again by February 15
and seemed recovered when on February 18 he ap-
peared irritable, refused supper and went to bed early.
At 2 :00 A.M. he was found in severe convulsion, with
high fever, followed by drowsiness and very rapid pulse
but negative neurological findings. At 4 :00 A.M. the
convulsion was repeated, the fever 104, the pulse 160
and the respirations 40. At 7 :00 A.M. the convulsion
was repeated again and the patient was taken to Hurley
Hospital. At 9 :00 A.M. the skin was carefully ex-
amined for petechiae as possible evidence of epidemic
meningitis, and none were found. At 9 :30 A.M. a
spinal puncture was done and the skin stood a vigorous
preparation with 7 per cent iodine followed by alcohol.
The spinal fluid, under 20 mm. mercury pressure,
showed three lymphocytes, negative Randy, negative
serology and a flat gold curve. During the day a blood
count and blood culture were made. The child took
fluids, was irritable when aroused but in general quite
stuporous with occasional carpo-pedal twitchings. The
temperature varied from 101 to 103. The pulse varied
from 160 to uncountable and the respirations from 60 to
80 a minute although the breathing was easy and the
chest clear. When the patient was seen at 5 ;00 P.M. the
same evening a few blebs at the corners of the mouth
and some on the forehead were noted, and the nurse
stated she had first noted these at about 3 :00 P.M.
These were typical inflammatory bullae, but on further
examination, loose patches of wet skin which peeled
away in sheets leaving red, raw oozing surfaces were
discovered on the chest, back, buttocks and glove
and stocking areas of the hands and feet. I have
emphasized the time relationships here to show how
quickly and completely the skin lesions developed. The
denuded areas, which denuded upon slightest trauma,
looked exactly like second degree burns when the skin
came off. With the diagnosis of pemphigus neonator-
um in mind sulfapyridine therapy was started, but
the dermolysis here seen is not to be confused with
the chronic slowly spreading bullous lesion described
in textbooks as pemphigus. Tannic acid 5 per cent in
a water-base jelly (a proprietary form) was used for
the desquamating areas, exactly as for burns, and all
areas subsequently healed exactly as for noninfected
burned surfaces. The blood count showed 45,000 w.b.c.
on admission and this rose, with the fever, to 60,000

w.b.c. in the first eighteen hours of treatment, and
then fell steadily (as did the fever) as the patient
improved during the next eight to ten days. After
eighteen hours of sulfapyridine therapy the tempera-
ture began its fall, the new areas of desquamation were
reduced and at twenty-four hours, the child had changed
from a drowsy moribund pallorous infant to an ill,
fretful, active child of good color. At forty-eight hours
the sulfapyridine was stopped because of diarrhea,
marked abdominal distension and vomiting. In eight
hours sulfathiazole was started and continued for the
next eight days and the child progressed steadily to
recovery.

The admission blood culture showed hemolytic Staph-
ylococcus aureus, and the same organism was again re-
covered on the third day, many colonies being obtained
from only two cubic centimeters of blood. The hemo-
globin showed a rapid decline after three days and three
small transfusions were given.

The medication consisted of 68 grains of sulfapyri-
dine in the first fifty-two hours of therapy, or a total
of 1.5 grains per pound per day. In the next eight
days the dose averaged 19 grains a day, or not quite
one grain per pound per day. All drugs were stopped
on the tenth day when the temperature had been nor-
mal for forty-eight hours. Recovery continued and has
been complete to date.

Discussion

One case warrants very little discussion, but
from the experiences of others, as reviewed in
the literature, and a consideration of this
case, I feel that epidermolysis is probably a
symptom and not a disease. It is probably a
symptom of a severe septicemia, usually due to
staphylococcus aureus, or of a severe toxemia
related to a staphylococcus infection, and that
Ritter’s disease, like severe pemphigus neona-
torum is probably an infant or neonatal form of
staphlococcic septicemia which may occur at later
times in childhood. Ritter’s disease is rarely re-
ported now. No one has ever matched his 297
cases, which suggests that its present rarity and
the increasing rarity since his day, as well as the
increasing rarity of pemphigus, is related to im-
proved general infant hygiene. I agree with
Ryan® that the new sulfonamide compounds offer
a great new hope in this disease and that if
further cases like these are reported, the very
fact that these drugs effect a cure is presumptive
evidence of the nature of the causative agent.
I point to the heavy doses of the drugs used
and urge that further observers take blood cul-
tures and report their cases. I feel that the
bullps or the extensive epidermolysis are toxic

970

Jour. M.S.M.S

REGISTRATION OF VITAL STATISTICS— KLEINSCHMIDT

phenomena and not due to infection primarily
although staphylococci are found in some blebs
and may be cultured from the oozing surfaces.

Summary

A case of wet exfoliative dermatitis associated
with hemolytic staphylococcus aureus septicemia
in a child of fifteen months is reported. It is
suggested that epidermolysis may be a symptom
of septicemia and that the two children’s diseases
showing this phenomenon, namely Ritter’s disease
and pemphigus neonatorum, may be related
staphylococcic septicemias. Chemotherapy now
seems to be the treatment of choice.

Bibliography

1. Cailliau, F. : Exfoliative dermatitis of nurslings. Post-

mortem. Ann. d’Anat. et Path., 11:911, (Dec.) 1934.

2. Daveo: Epidemic pemphigus of the newborn. Ritter’s

disease. Bulletin de la Soc. d’Obst. et de Gynec., 24:150,
(Feb.) 1935.

3. Elias, H. : Contributions to study of Ritter’s disease (three
cases). Clin, Pediat., 16:47 Qan.) 1934.

4. Flusser, E. : Acute dermatitis of the newborn. Monat-

schrift f. Kinderh., 67:279, 1936.

5. Hart, F. D.: Pemphigus neonatorum. Two epidemics.

Brit. Jour. Derm, and Syph., 50:118, (March) 1938.

6. Kendall, Norman: Ritter’s disease: Case report with autopsy.
Jour. Ped., 15:133, (Nov.) 1939.

7. Raschkes, I. : The question of dermatitis. Exfoliativa

neonatorum. Archiv. f. Gynak., 139:669, (Jan. 27) 1930.

8. Ryan, N. W. : Ritter’s disease treated with sulfapyridine.

Am. Jour. Dis. Children, 59:1057, (May) 1940.

f\/|SMS

IS THE DANGER PAST?

On September 24, Mr. Charles A. Togut, speaking
before the National Fraternal Congress of America,
warned that state or governmental medicine will par-
alyze the country’s fifty million voters and destroy the
private practice of medicine. He said :

“National Defense has catapaulted the issue of the
‘Nation’s Health’ onto the front page of every news-
paper and onto the burning wires of every radio trans-
mitter. As in nations ruled by the sword, malicious,
propagandists are piercing the heart of our incompa-
rable system of medical care.

“The Congress of the United States is weighing the
destiny of our peoples and of our doctors with numer-
ous authoritarian legislative medical measures. The
battle of the century, the government versus the Amer-
ican Medical Association, is but a prelude to the condi-
tioning processes of a National Planned Medical Care
Program, unless the American peoples, the doctors, the
industrialists, the leaders of labor and capital can
smother the most powerful propaganda factory in the
world and inaugurate fighting means and methods to
unite the leaders of medicine and industry in a pro-
gressive Health Insurance Movement.”

Today there is greater cause for fear and a greater
need for constant and intelligent vigilance than at any
previous time if the independence of medicine is to be
preserved. — National Physicians Committee.

December, 1941

Movement for the Registration
of Vital Statistics

By Earl E. Kleinschmidt, M.D., Dr.P.H.
Chicago, Illinois

Earl E. Kleinschmidt, M.D., Dr.P.H.

B.S., University of Mich-gan, 1927; M.S.,
University of Michigan, 1928; M.D., Univer-
sity of Michigan, 1930; Dr.P.H., University
of Michigan, 1936. Diplomate, National Board
of Medical Examiners, 1931. Assistant Editor-
in-Chief, ‘‘Journal of School Health,” 1935
to present. Chairman, Department of Pre-
ventive Medicine, Public Health and Bac-
teriology, Loyola University School of Medi-
cine, 1938 to present. President, American
School Health Associatioji. Member, Michigan
State Medical Society.

Efficient registration of births, marriages, and deaths
has so many points of moral, legal, and commercial
interest, that we might expect more earnest calls upon
the law makers from other sources. But experience
proves that none realize its importance so much as the
medical statistician, and on us devolves the duty of
pressing its claims.

J. H. Beech, M.D., Coldwater, 1857.^

■ Prior to 1850 the only available statistics of

Michigan consisted of census returns made in
1840 by the federal government.^ This was the
first census of Michigan as a state. It was re-
corded at that time as having 212,267 inhabi-
tants.^ In 1850, this number had increased to
397,654, a gain of 185,387 persons ; in 1860 the
State had 749,113 inhabitants; and by 1870 it
had increased to 1,184,059 people;^ making it the
thirteenth state® in point of population.

In 1856, a law was enacted which required the
registration of marriages, but it was carelessly
observed. “So little attention has been paid to
it,” said Dr. N. B. Stebbins of Detroit, “that the
records in the clerk’s office in the county of
Wayne — the most populous county in the State
— show, as we are informed, that only 419 mar-
riages were recorded in that office for the year
1856.”® The law had many imperfect features,
and accordingly those entrusted with the duty of
carrying out its provisions, though subject to
heavy penalty for neglect, wilfully ignored its
provisions. One reason perhaps that accounted
for this state of affairs was the fact that no
annual report was required of the registrars.'^

^Pen. Jour. Med., 4:535, (April) 1857.

^Jour. House of Rep. State of Michig-an, 1:11, 1872.

^Loc. cit.

^Loc. cit.

5J^OC, Cit

Mbid’.. 3 1613. 1857: An. Rep. M.S.M.S., 1:91, 1859.

^An. Rep. M.S.M.S., 1 :84, 1859.

971

REGISTRATION OF VITAL STATISTICS— KLEINSCHMIDT

Efforts of State Medical Society to Secure
Registration Law

As is indicated by the quotation found at the
beginning of this article, the medical profession
had a deep interest in the proper registration of
vital statistics in the state. This interest mani-
fested itself soon after the State Medical So-
ciety was organized in 1853. The physicians
most responsible for initiating the movement for
the establishment of a registration law in the
state were the following : Dr. J. H. Beech of

Coldwater, Dr. N. B. Stebbins of Detroit, Dr.
J. Adams Allen of Kalamazoo, Dr. George B,
Wilson of Port Huron, Dr. J. J. Noyes of De-
troit, Dr. J. H. Jerome of Saginaw City, and
Dr. Zina Pitcher of Detroit.

Perhaps the most important influence which
served to stimulate Michigan physicians to take
steps in this direction were the activities of the
American Medical Association. In 1853, Dr. B.
R. Welford of Virginia, in his presidential ad-
dress, urged the enactment of laws in various
states for the securing of a uniform system of
registration of births, marriages, and deaths.®
During this same meeting a committee was ap-
pointed of which Dr. N. B. Stebbins of Detroit
was a member.® This committee “On Registra-
tion of Marriages, Births, and Deaths” subse-
quently made an extensive report at the ninth
annual meeting of the Association at Detroit in
1856. The summary of this report was as fol-
lows :

1. The Secretary, or some other officer of State,
shall prepare and circulate to the towns, cities, or
counties as the case may be, blank forms, for
returns, based upon the system and nosological
arrangement adopted in the preparation of the
mortality statistics of the last census of the United
States. (It has been suggested that mumps be
added to the list of diseases.)

2. The birth of every child shall be recorded by the
parent or owner of the child, stating distinctly
the time of its birth, the name and nativity of both
its parents, and whether it be the first, second or
any other number, by the same parents.

3. Every marriage shall be recorded by the person
who solemnizes the marriage contract, stating the
names and nativity of both parties.

4. Every death shall be recorded by the person hav-
ing charge of the premises on which the death
shall have occurred, and the record shall distinctly
set forth the cause of the death, according to the
certificate of the physician having had charge of

®Pen. Jour. Med., 1 :43, 1853.

»Ibid., 3:24, 1855.

the patient, or according to the best of his infor-
mation which can be obtained, together with the
name, activity, age, sex, color, and occupation of
the deceased ; and these several records shall be
given to the clerk of the town, city, or county,
as the case may be, and he shall make a return
of them, according to the blank forms which he
shall have received, to the Secretary or other
officer of State who shall annually publish the
same.i<>

In 1858, at a similar meeting held at Wash-
ington, D. C., by the American Medical Asso-
ciation, Dr. George Mendenhall of Ohio, Chair-
man of the Committee on Medical Topography
and Epidemic Diseases of Ohio, Indiana, and
Michigan, recommended to the assembly that
Congress be petitioned to pass a law by which
a uniform system of registration might be adopt-
ed by all states for the purpose of obtaining cor-
rect vital statistics by those whose duty it would
be to take the census of 1860.^^

Steps being taken by other states also influ-
enced Michigan physicians to work for a law of
this kind. A pioneer in many ways, Massa-
chusetts was the first state to collect vital sta-
tistics in this counti^'.^^ It had passed a law for
the collection of statistics of births, marriages,
and deaths as early as 1842.^® The first annual j
report was made February 7, 1843.^^ The pri-
ority of this achievement is apparently disputable,
for according to available records. Dr. B. R.
Welford of Virginia, on the occasion of the
sixth annual meeting of the American Medical
Association at New York, reminded his listeners
that his state had set the example for other
states by the enactment of a law for the regis-
tration of marriages, births, and deaths.^® New
York passed such a law in 1847, making its first
annual report in April, 1848.^® Ohio passed a
similar law in 1856.^^ By 1859, Rhode Island,
Connecticut, New Jersey, Kentucky, Vermont,
and South Carolina had passed laws for the reg-
istration of bfrths, marriages and deaths.^®

According to available accounts, the provisions
of these laws already enacted in other states were

^®An. Rep. M.S.M.S., op. cit., p. 89.

^iPen. and Ind. Med. Jour., 1 •.667, 1859.

«Jour. H. of Rep. State of Mich., 2:1149, 1867.

«An. Rep. S.B.H., 9:108.

^qour. H. of Rep. State of Mich., op. cit.

'®Pen. Jour. Med., 1 :43, 1853.

^®Jour. H. of Rep. State of Mich., op. cit.; The New York
system of registration of births and deaths was originated by
Dr. Thomas C. Brinsmade of Troy, N. Y. who for 20 years
kept a tabulated view of his practice. (An. Rep. M.S.M.S., op.
cit., p. 79.)

’’Pen. and Ind. Med. Jour., 1 :667, 1859.

’*An. Rep. M.S.M.S., op. cit., p. 83.

972

Jour. M.S.M.S.

REGISTRATION OF VITAL STATISTICS— KLEINSCHMIDT

carefully scrutinized by physicians in Michigan.
In his report as Chairman of the Committee
on Vital Statistics of the State Medical Society
in 1859, Dr. George B. Wilson of Port Huron
praised the method of registration being car-
ried out in New York State, and urged that a
similar method be adopted by the Legislature of
Michigan.^® Apparently the registration law
of Ohio failed to function properly at the start,
for Dr. George Mendenhall, Chairman of the
Committee on Medical Topography and Epidemic
Diseases in Ohio, reported in 1858 at the meet-
ing of the American Medical Association in
Washington, D. C., that he was unable to se-
cure any data on births, deaths, and marriages
because of “culpable inattention on the part of
those whose duty it was to furnish blanks and
collect information for these statistics.”^”

Cognizant of the trend of events elsewhere,
particularly as revealed in the several reports
made at meetings of the American Medical Asso-
ciation,^^ several Michigan physicians took steps
to interest others in the subject at meetings of
district and state societies. At a meeting of the
State Medical Society on March 26, 1856, Dr.
J. H. Beech of Coldwater read a paper on “Ob-
servations of Diseases at Coldwater, Michigan in
1855.” In this report he presented a record of
mortality according to age.^^ At this same meet-
ing, Dr. Zina Pitcher of Detroit called attention
to some Registration Reports of the State of
Rhode Island for the years 1853 and 1854, which
on motion were referred to Dr. N. B. Stebbins
for further study.^®

“The publication of the statistics which
would be collected by a well-matured and rig-
idly enforced registry law,” said Dr. Stebbins
the following year at a similar meeting held
at Lansing, “would serve as an annual lesson
on the laws of human life in their operation
upon ourselves, a kind of practical physiology
taught in all our towns and at every fire-
side, far more instructive and impressive than
any derived from books teaching the principles
and laws of life developed by our national
constitution, as actually existing under sur-

«Ibid., p. 78.

**Pen. and Ind. Med. Jour., 1 :667, 1859.

”At several meetings of the American Medical Association in
the period 1847-1858, recommendations were made to the differ-
ent states to adopt a regular system of registration of births,
marriages and deaths. (Pen. and' Ind. Med. Jour., 1 :176, 1858.)

“Pen. Jour. Med., 3 :497, 1856.

“Ibid., p. 495.

December, 1941

rounding influences, and pointing to the means
for their improvement and modification.” And
he further asserted, “Statistics of mortality,
showing the extent and causes of death in
different localities have been demonstrated by
the experience of those States and countries
where such a law exists, as of the first impor-
tance in many respects. In determining
whether death in certain cases results from
natural causes or otherwise, whether by dis-
ease or violence, murder, or accident, it has
been frequently found of the greatest mo-
ment in the trial of important causes in the
courts. Much information would also be
elicited as the influence of occupation upon
health, in regard to hereditary taint, and it
would do much too, to awaken the public to
the necessity of preventing the introduction
of pestilential diseases. Not the least of these
is the facility it would afford in collecting
statistics of population, in ascertaining the
relative number of births to deaths, and of
males to females.” “It is to remedy the de-
fects of the law,” he said, “so as hereafter to
compel a more general compliance with it,
and to couple with it a provision also requir-
ing a careful and faithful registry of all the
births and marriages in the State, that the
action of the Legislature is now required.”^

The meeting of the State Medical Society the
following year saw many things transpire which
were to further intensify interest in the problem
so ably discussed by Dr. Stebbins. Of utmost
significance were the remarks of Dr. J. Adams
Allen, President of the Society. “The profes-
sion should combine to secure periodical and
complete reports of the three principal epochs in
every person’s history,” said Dr. Allen, “viz.,
birth, marriage, and death. Without this clue
there can be no rational comparison of the rela-
tive salubrity of different districts of the country,
nor any accurate data upon which to found one
of the most important problems of political econ-
omy ; namely, given a certain population in a
particular district, how long before it will be
doubled or reduced to a moiety? — a question in-
volving the very highest interests of the com-
monwealth. A registration of births and deaths
combined with periodical reports from the vari-

“Ibid., 4:615, 1857.

973

REGISTRATION OF VITAL STATISTICS— KLEINSCHMIDT

ous entreports of immigration, would furnish a
reliable constant census — I need not speak here
of its advantages in a merely civil point of view,
inheritances and the like, but considered only in
a professional light — it would tend to the elucida-
tion of a vast number of unexpected truths.”
Referring to the vast amount of propaganda be-
ing spread elsewhere relative to the supposed
unhealthfulness of Michigan, he said, “This error
a faithful registration would speedily dispel and
the augmented population and wealth which
would then throng upon us to improve our
matchless resources, our soil of unsurpassable
fertility, and inexhaustible store of mineral and
forest riches, would quickly repay thousand fold
the trivial expense involved.”^

So impressed were the members of the Society
with Dr. Allen’s views that a committee was
appointed in an endeavor to carry them out, and
Dr. Allen was made chairman of this commit-
tee.^®

During the same meeting. Dr. N. B. Stebbins
of Detroit submitted a report on registration.
Dr. Stockwell of Port Huron read a volunteer
paper by Dr. Geo, B. Wilson, also of Port
Huron, on the “Necessity and Proper Method
of Obtaining Vital Statistics.” This was en-
thusiastically received by the membership, and
Dr. Wilson voted the thanks of the Society.
In addition. Dr, J. H. Beech of Coldwater pre-
sented: a paper embracing the vital statistics of
Coldwater for 1858. Records of mortality, tem-
perature, wind, clouds, and storms were exhibited
by Dr. Beech.^’^

Efforts to lay the matter of a registration law
before the legislature were made in 1857, and
again in 1859. As chairman of the Committee
on State Affairs in favor of a law for the Reg-
istration of Marriages, Births, and Deaths, Dr.
N. B. Stebbins labored for the passage of such
a bill in 1857, but owing to the shortness of the
legislative session and the amount of business
to be transacted, the bill was left untouched.^®
At the meeting of the State Medical Society
in 1859, Dr. Stebbins recommended that a com-
mittee be appointed to report a resolution and
petition in favor of a registration law to be en-
acted by the legislature during the current ses-

“An. Rep. M.S.M.S., op. cit., p. 18.

®*Ibid., p. 6; Pen. and Ind. Med. Jour., 1:702, 1859.

®^Pen. and Ind. Med. Jour., 1 :703, 1859.

2«Pen. Jour. Med., 4:613, 1857.

974

sion.^® Dr. Beech offered a resolution to the
same effect as follows :

Resolved, That this Society earnestly recommend
to the Honorable the Senate and House of Representa-
tives that they do, at the earliest practicable date, en-
act the necessary laws requiring and providing for
the thorough registration of births, marriages, and
deaths, occurring in this State.^°

Shortly afterwards petitions were circulated
among the physicians of the state by the Com-
mittee on Vital Statistics consisting of Drs, Geo.
B. Wilson and Stockwell of Port Huron as
follows :

To the Honorable the Legislature of the State of

Michigan ;

Your petitioners, the undersigned citizens of this
State, respectfully pray your Honorable Body to pass
a law requiring the registration of Births and Deaths
occurring in this State, the registration to fully exhibit
the name of parents, and place of birth. The regis-
tration of deaths to exhibit the name, age, sex,
occupation, disease, and place of residence of the
deceased. The value of such a registration in fur-
nishing proper statistical tables to exhibit the general
health of the State, and the ratio of deaths as com-
pared with other portions of the country cannot fail
to appear on the increased emigration to the State.

This attempt to secure a registration law was
frustrated by events associated with the impend-
ing war. Lack of medical publications during
the next few years made further inquiry im-
possible.

The Enactment of a Registration Law

With the close of the Civil War, physicians
returned to civil life and their former pursuits.
According to available accounts of medical ac-
tivities for this period, one of the first subjects
to engage their attention was the matter of a law
to provide for proper registration of births, mar-
riages, and deaths. Interest in this subject was
apparently intensified by the lessons taught by
the war.

At a meeting of organization of the State
Medical Society on June 5, 1866, a committee on
“Vital Statistics” was appointed to resurrect in-
terest in a registration law.®^ On motion of Dr.
J. H. Jerome of Saginaw City, this committee
was to take immediate action. To the committee

^An. Rep. M.S.M.S., op. cit., p. 88.

^®Pen. and Ind. Med. Jour., op. cit., p. 703; An. Rep. M.S.
M.S., op. cit., p. 10.

»Ubid., p. 75.

“Trans. M.S.M.S., 1:20, 1867 and 1868.

Jour. M.S.M.S.

REGISTRATION OF VITAL STATISTICS— KLEINSCHMIDT

were named .Drs. Stewart and Noyes of Detroit,
and Richardson of Niles. Later in the meeting
it reported that “No provision existed in the State
for keeping such statistics.

Apparently other events were to assist the
State Medical Society in its efforts to secure a
registration law for the state. Following the
close of the war, many people claimed pensions
and dues from the federal and state governments
because of the death of relatives and other losses
incurred dn the war.^® Government officials, how-
ever, were confronted with an imperfect record
system which made the legal aspects of this work
most difficult to carry out. Their attention was
thus drawn td the necessity for a new law at a
most critical time in the history of the state, but
at a time that was certain to bring out the inade-
quacies of the system then in use.®® J. J. Wood-
man, Chairman of the Committee on State Af-
fairs of the House of Representatives commented
as follows on one occasion in February, 1867,
“The subject of a registration law for births,
marriages, and deaths in this State, was brought
before the Legislature for consideration at a
former session and although the measure was not
then enacted into a law, it has in the meantime
lost none of its importance or usefulness. The
only means in this State, at present,” he said,
“for obtaining information collected through an
efficient registration law, are, (1) that collected
through the State and United States census,
which are taken only once in five years; and (2
that of our State law for the registration of
marriage certificates by the county clerk.”®^

By 1867, States having registration laws in-
cluded Massachusetts, New York, New Jersey,
Connecticut, Vermont, Rhode Island, New
Hampshire, Pennsylvania, Kentucky, and South
Carolina.®®

Efforts to secure a similar law in Michigan
took shape early in 1867. Memorials were di-
rected to the legislature from all parts of the
state by physicians and other citizens, requesting
the benefits of a system of registration of births,
marriages, and deaths. Among the more im-
portant were the following: A memorial from

*’Det. Rev. Med. and Pharm., 1:191, 1866.

®*Trans. M.S.M.S., op. cit., p. 23.

*®An. Rep. Reg. of Births, etc.. Secretary of State, 1 :2, 1868.
**Loc. cit.

®’Jour. H. of Rep. State of Mich., op. cit., p. 1149.

®*Loc. cit.

December, 1941

the Northeastern Medical Society embracing
the counties of Oakland, Lapeer, Macomb, St.
Clair, and Sanilac. This read as follows :

Resolved, That we, as a medical society, recognizing
the importance and utility of a registration law in this
State would most respectfully and urgently recommend
to the Legislature, now in session at Lansing, Michigan,
to pass a law providing for the registration of births,
marriages, and deaths in this State.*®

On January 16, 1867, the Hon. Seth K. .Shet-
terly, representative from the second district of
Macomb county, having given previous notice,
and having been granted leave, introduced a bill
to provide for the registration and return of
births, marriages, and deaths to the House of
Representatives.^® This became known as House
Bill No. 219, “A Bill to Provide for the Registra-
tion of Births, Marriages, and Deaths. On re-
ceipt of the original bill prepared by the Hon.
Shetterly and the sponsors of the bill, the Com-
mittee on State Affairs revised it, preparing a
substitute which they sent back to the House of
Representatives recommending that the substitute
be passed: In the words of the Hon. J. H.

Woodman — “thinking that a law more simple in
its provisions, and less expensive in its operations
would be more acceptable to the people of the
State, your committee has prepared a substitute
for the bill.”^® The Senate returned the bill with
an amendment providing, “That no person shall
be required to answer any question which will
tend to criminate himself or herself, upon any
such examination.”^® The changes thus incor-
porated into the original bill were later to make

“Det. Rev. Med. and Pharm., 2 :204, 1867 ; also a memorial
from Dr. N. B. Stebbins, in behalf of the Wayne County Medical
Society; also the petition of Edward Cox, S. S. French, N. M.
Campbell, E. G. Slater, W. G. Sanders, and James A. Dean,
physicians of Battle Creek; D. D. Lamond and twenty-eight
other citizens of Genesee county; J. H. Beech and fourteen
other citizens of Branch county; E. Boyland and twenty-three
other citizens of Wayne county; B. Aldrich and forty-two other
citizens of Macomb county; D. A. Past, J. Tripp, Wm. G. Cox,
and eight other citizens of Ypsilanti; \V. R. Nims, and eight
other citizens of Sanilac county; Earl Smith and twenty-four
other citizens of Burlington, Calhoun county ; H. B. Shank,
M.D., G. E. Ranney, M.D., I. H. Bartholomew, M.D., H. B.
Baker, M.D., W. C. Payne, W. Jones and Daniel L. Case,
physicians and citizens of Lansing; Watson Loud and seven
other physicians of Romeo, and vicinity; Samuel A. Babbitt,
M.D., and six other citizens of Washington, Macomb county;
O. E. Bell, M.D. and twelve other citizens of Oxford, Oakland
county ; Chas. Shepard and eighteen other citizens of Grand
Rapids ; A. P. Drake, M.D., and thirteen other citizens of
Barry county; Wm. Brownell, M.D., and ten other physicians
and citizens of Utica and vicinity; E. C. May and twenty-one
other citizens of Livingston county; J. Paddock, M.D., and
six other physicians of the city of Pontiac; M. C. Kenny, M.D.,
and twenty-one other citizens of Lapeer county; E. G. Beriw,
M.D., and seven other physicians of Branch county ; and J. L.
Valade, M.D., and eight other citizens of Monroe county.
(Jour. H. of Rep. State of Michigan, 2:1148, 1867.)

^»Ibid., 1:183, 1867.

«Ibid., 2:1548, 1867.

«Ibid., p. 1155.

«Ibid., p. 2539.

975

REGISTRATION OF VITAL STATISTICS— KLEINSCHMIDT

the functioning of the law most difficult. The
bill was finally passed by a vote of 65 to 13.^
Mr. Shetterly moved that the bill be ordered to
take immediate effect. For some reason not as-
certainable in available literature, he later with-
drew his motion. The bill was laid on the table
temporarily, but was finally approved and be-
came a law on March 27, 1867.^®

As originally enacted, the law provided for
the assistance of a committee composed of
physicians from the State Medical Society
and the Medical Faculty of the University of
Michigan.^® This committee was expected to
assist the Secretary of State in the prepara-
tion of the annual registration reports. As
pointed out later by Secretary Baker, this did
not provide the Secretary of State with ade-
quate medical assistance on which he could
depend. It is of interest also to learn from
Dr. Baker that “no committee was appointed
to supervise the work of the Reports by either
of the bodies of medical men mentioned in the
law.”^"

In preparing the first annual report of the vital
statistics of the state, the Secretary of State was
assisted by Dr. I. H. Bartholomew of Lansing
who “rendered valuable assistance in the nomen-
clature and classification of diseases.”^®

Dr. Bartholomew at the time was chairman of
the Committee on Vital Statistics of the State
Medical Society.^® His work also was evidently
well esteemed by the State Medical Society, for,
at Dr. Geo. Ranney’s suggestion, a resolution
was passed by the Society thanking him for his
labors upon the report.®”

In the following year, assistance was rendered
the Secretary of State by Dr. Geo. Ranney, also
a member of the Committee on Vital Statistics of
the State Medical Society.®^ He was largely re-
sponsible for the second annual report of 1869
for which he also received the thanks of the
Secretary of State and State Medical Society.®^

■•^Loc. cit.

^®An. Rep. Reg. of Births, etc., Secretary of State, 1 :19S,
1868.

^®Ibid., p. 199; Trans. M.S.M.S., 24:2, 1894.

*^An. Rep. Reg. of Births, etc.. Secretary of State, 4:15, 1872.

^*Trans. M.S.M.S., I (1869), 12; the first annual report of
vital statistics included a single table of results of meteorological
observations made at the Agricultural College during 1867 by
Prof. R. C. Kedzie. (An. Rep. S.B.H., 9:114.)

^"Loc. cit.

®®Ibid., p. 16.

®*An. Rep. Registration and Return of Births, Marriages and
Deaths, II (1868), iv.; Trans. M.S.M.S., 1:13, 1870.

®nbid., D. 17.

In 1869, the task fell to Dr. Henry B. Baker
of Wenona, a new member of the Committee on
Vital Statistics of the State Medical Society.®®
He retained the position of Registrar of Vital
Statistics until 1873, at which time he became
Superintendent of Vital Statistics and Secretary
of the State Board of Health.®^ He remained
in close touch with the system of vital statistics
until 1883 when by an act of the legislature the
work was practically withdrawn from all medical
supervision.®®

In the preparation of the annual registration
reports, the Secretary of State, the Hon. Oliver
L. Spaulding, was greatly influenced by the work
being carried out in Massachusetts. In the first
annual report, he freely acknowledged his obliga-
tion to the Secretary of State of the State of
Massachusetts, the Hon. Oliver Warner, “for
reports, forms of blanks, and information”
furnished him.®”

Imperfections of Original Registration Law

From the very time that the registration law
was first put into effect it was realized by the
Secretary of State and those physicians who
assisted him, that it possessed many imperfec-
tions which detracted from its efficiency.®’^ As
explained Dr. I. H. Bartholomew, “The reason
why a better registration law was not passed by
the legislature, was, that the members were
wholly unacquainted with the needs of the medi-
cal profession in this respect.”®®

Supervisors and assessors of counties in the
state neglected to report births and deaths, alleg-
ing that they received no additional salary for
this increase of their duties.®” Moreover, certain
provisions relative to the time for gathering birth
and death statistics also caused poor returns.
According to the law, the supervisor or assessor
was not expected to ascertain by inquiry of the
inhabitants the births and deaths which had oc-
curred in their respective townships, cities, or
wards during the year until the tenth day of
April to the first day of June of the year follow-
ing.®” As Dr. H. O. Hitchcock pointed out, there
were three major sources of error:

®*Trans. M.S.M.S., 24:2, 1894.

®^An. Rep. S.B.H., 10:38.

“Trans. M.S.M.S., op. cit., p. 2.

“An. Rep. Registration and Return of Births, Marriages and
Deaths, op. cit., p. vii.

®^C. L. Wilbur, “Registration of Vital Statistics in Michigan,”
Trans. Michigan State Medical Society, 24:2, 1894.

®8Trans. M.S.M.S., 1:17, 1867.

®»Ibid., p. 39.

“An. Rep. S.B.H., IV, 10.

976

Jour. M.S.M.S.

REGISTRATION OF VITAL STATISTICS— KLEINSCHMIDT

1. The time during which these inquiries are to be
made — more than a year after many of the events have
transpired — would be pretty sure, either from forget-
fulness or from change of location, to lead to a great
number of omissions.

2. These facts are to be ascertained by actual in-
quiry or otherwise, as the indolence, carelessness, or
indifference of the officer may suggest as the easiest
way to satisfy the state, which makes no provision for
determining the faithfulness or punishing the unfaith-
fulness of those to whom it commits this duty. The
fee paid for each recorded case is not sufficient of it-
self to induce great accuracy, nor are there any methods
provided for proving the accuracy of these reports.

3. The supervisor or assessor may fairly be presumed
to be not a physician, and with no special qualifications
for ascertaining exactly or recording with accuracy, of
what disease any person may have died several months
or a year before. He must take the statement of the
family, friends or neighbors ; and how much reliance
there is to be placed upon the memory of such per-
sons as to the cause of a death that took place months
before, any educated physician can understand who
knows how his diagnosis of disease is, often at the
time of making it, falsified or caricatured by ignorant
and forgetful friends and prejudiced neighbors.®^

To overcome this latter difficulty it was sug-
gested by Dr. Baker that the office of registrar be
created in each city and township of the state.®^
“In my opinion,” said Dr. Baker, “this Chief
Medical Officer of Health which should exist in
every city, village, and township, is the proper
person to take charge of the statistics of births,
and deaths in such city, village and township.”^^

Following his appointment as Registrar of Vi-
tal Statistics in 1869 and thereafter until he be-
came Superintendent of Vital Statistics, Dr.
Baker made many suggestions to the Secretary^ of
State for the improvement of the Registration
Law.®^ In his frequent appearances before meet-
ings of the State Medical Society, he also took
occasion to point out needed changes in the law
to the physicians in attendance at these meetings.®®

Dr. Hitchcock was likewise a frequent speaker
on the subject at medical meetings. In his an-
nual address before the State Board of Health in
1876, he stated that, “One of the strongest and
most persistent efforts of this Board should be
to secure more complete and reliable vital statis-
tics of the people of Michigan.”®® He objected
to the gathering of these statistics by supervisors

®^Loc. cit.

«2Ibid., p. 127.

®’Loc. cit.

®^An. Rep. Reg. and Return of Births, Marriages and Deaths,
op. cit., 6:xi, 1872.

“Trans. M.S.M.S., 3:82,1872.

“An. Rep. S.B.H., 4:9.

December, 1941

and assessors claiming that they should be gath-
ered by those persons who were participants in
the event as physicians, midwives, sextons, and
parents. He also was in favor of assessing pen-
alties for those who failed to enforce the law.®’’
As might be expected, the several sources of
error already pointed out did lead to imperfect
returns of birth, marriage and death statistics,
thus depreciating the value of those which were
gathered. For many years, at least forty per cent
had to be added to the reported deaths in order
to approximate the probable number of deaths,
according to MacClure.®® In 1871, Dr. Baker de-
clared on one occasion that not more than fifty-
five per cent of the actual deaths in the state
were reported.®^ As for the systems of vital sta-
tistics in the cities of the state, conditions at this
time were still w^orse. Speaking before the Sani-
tary Convention of Grand Rapids, in 1880, Dr.
Baker declared, “The vital statistics of the city,
which lie at the very foundation of effective pub-
lic health service, have never been properly col-
lected. No tables carefully compiled under the
immediate supervision of a medical man or vital
statistician are regularly published by any city in
Michigan.”’’® In 1880, at a meeting of the State
Board of Health, Dr. H. F. Lyster called atten-
tion to the lack of accurate statistics in Detroit.’’^
“One of the great disadvantages which the Board
had to contend with through most of its exist-
ence,” said MacClure, “was the imperfect re-
turns of deaths.”’^

In the course of time many attempts were
made to improve on the original registration law
of 1867. Compensation of supervisors and as-
sessors who gathered the statistics was openly
advocated by Secretary of State O. L. Spaulding
in 1870 in order to encourage better reporting;’®
this suggestion was made again in 1883 by the
Hon. LeRoy Parker of the State Board of
Health.’^ The Committee on Vital Statistics of
the State Medical Society repeatedly exhorted the
physicians of the state to make their statistics
“as full and perfect as possible.”’® At the annual
meeting of the Society in 1872, a committee was
appointed to study a portion of President Hitch-
cock’s address which dealt with vital statistics

®Tbid., p. 11.

“MacClure, op. cit., p. 23.

“An. Rep. S.B.H., 4:10.

™Ibid., 8:129.

^^Ibid., p. xlv.

■^^MacClure, op. cit., p. 23.

^®An. Rep. Reg. and Return of Births, Marriages and Deaths,
3:4, 1869.

’^An. Rep. S.B.H., ll:xxxii.

■®Trans. M.S.M.S., op. cit., p. 83; ibid., 1:16, 1869.

977

REGISTRATION OF VITAL STATISTICS— KLEINSCHMIDT

and preventive medicine. The deliberations of
this committee, which followed, ultimately led to
the creation of the position of State Superintend-
ent of Vital Statistics.'^®

Attempts to amend the law by legal methods
were repeatedly made by members of the State
Medical Society. The first attempt in 1869, so
the records point out, was successful. Act No.
125, Session Laws of 1869, was approved April
3, 1869.'^^ This amendment made the registration
year identical with the calendar year. From then
on the attempts made were generally unsuccess-
ful, or fell short of their goal. In 1871, another
amendment to amend Section 3 of Act No. 125
of the Session Laws of 1869 met with so much
opposition from both branches of the legislature
that it failed to pass.'^®

At the annual meeting of the State Medical
Society in 1872, the Committee on Vital Statis-
tics made recommendations in a lengthy report
to secure more full and accurate returns of
births, diseases and mortality. Available records,
however, fail to explain what action the Society
took.'’^®

In 1876, at a similar meeting, Dr. Baker made
the recommendation that a committee be appoint-
ed to draft a memorial to the legislature for the
enactment of a law amending the law for the
collection of vital statistics.®® This suggestion
was accorded a favorable reception, and a com-
mittee consisting of Drs. Baker and Hitchcock
was appointed to draw up such a bill and to
report at the next regular meeting.®^ Again for
some reason that the records fail to reveal, no
further mention of the undertaking is made at
the next meeting.

Again in 1878, Prof. R. C. Kedzie recommend-
ed to the Society that a committee be appointed
to prepare a suitable bill which should incorpo-
rate the needed changes. He further recommend-
ed that this committee bring the subject before
the legislature for their consideration.®^ Dr.
Baker and the Hon. LeRoy Parker were named
to the committee, but again the sources perused
fail to disclose any further action being taken.®®

Not until 1897 did the members of the med-
ical profession finally succeed in getting a more

’•Ibid., 3:41, 1872.

”An. Rep. Reg. and Return of Births, Marriages and Deaths,
1:195, 1869.

’•Trans. M.S.M.S., 24:4, 1894.

’®Det. Rev. Med. and Pharm., 7 :323, 1872.

•®An. Rep. S.B.H., 5:130.

•’Ibid., p. Iv.

**Ibid., 6:8.

••Ibid., p. liv.

978

desirable law passed which would bring about
the needed changes. This law provided for im-
mediate return of birth, marriage, and death
reports.®^

Role of Dr. Henry B. Baker

In the foreground always. Dr. Baker labored
incessantly to improve the vital statistics of the
state, from the time he came to Lansing in 1869
to assist in the preparation of the annual regis-
tration reports, until the system of collecting
vital statistics became more accurate. For sev-
eral years prior to Dr. Baker’s becoming the
Superintendent of Vital Statistics, the need for
a medically trained statistician had demonstrated
itself to the Secretary of State responsible for
carrying out the Registration Law. “In the prep-
aration of this report (1870),” said the Hon. j
O. L. Spaulding, “the services of a physician of |
recognized ability and standing in the profes- j
sion are not only desirable, but almost indis- I
pensable.”®® The Hon. Daniel Striker, who sue- *
ceeded Mr. Spaulding, went even a step further.

In his introductory remarks to the fourth reg-
istration report, he stated that the preparation
of vital statistics called for the services of “an
experienced statistician, who should be a phy-
sician of recognized ability and standing in the
profession.” “The law,” he said, “should provide
compensation corresponding with its require-
ments.”®® Dr. Baker’s excellent work won for
him immediate reputation. Each annual report
carried words of praise for him from the Secre-
tary of State. Said the Hon. O. L. Spaulding of
Dr. Baker in 1870, “I take pleasure in acknowl-
edging my obligation, and to whom is due what-
ever of merit it (referring to the Registration
Report of 1869) may contain. Possessing a rare
fitness and ability for the work, he has devoted
to it much time and labor. ”®^ Coming to Lansing
finally in October, 1870, to superintend the com-
pilation of vital statistics, he soon became an ar-
dent advocate of everything pertaining to prevent-
ive medicine, and as such became one of the most
powerful figures in the movement for sanitary
reform.®® Typical of the wisdom he showed

•’MacClure, op. cit., p. 23.

••An. Rep. Reg. and Return of Births, Marriages and Deaths,
op. cit., p. 4.

••Ibid., 4:v, 1870.

•’Ibid., Ill, 4.

••MacClure, op. cit., 9; at a meeting of the state medical
society. President I. H. Bartholomew appointed Dr. A. B.
Palmer of Ann Arbor to assist the Secretary of State with the
preparation of the Registration Report. Dr. Palmer, however,
gave way to Dr. Baker in order that “the effort for the pro-
posed State Board of Health might be better subserved. (Loc.
cit.)

Four. I^I.S.M.S

PRESACRAL RESECTION— SCULLY

in whatever he set his mind to, is a report he
made at a National Conference of State Boards
of Health in 1886 relative to the adoption of a
uniform system of vital statistics for the United
States and Canada. It was his opinion that to
adopt such a system as was proposed would be
to adopt permanently an imperfect system. In-
stead, he advised that each state and province
employ a man to perfect a system within his
own state before such a system be contem-
plated.®®

Social Statistics

Another form of statistics that received at-
tention from legislators at about this same period
was social statistics. On complaint of the
Census Bureau at Washington in 1870 of “the
great difficulty in obtaining from this state what
are termed social statistics,” Gov. Henry P. Bald-
win recommended legislation to secure such
statistics in Michigan in July, 1870, and in Sep-
tember of the same year the legislature passed a
law for this purpose.®^

*9 An. Rep. S.B.H., XIV, 187; in 1878, Dr. Baker was ap-
pointed to a committee to confer with other similar committees
m other states relative to a uniform plan for the registration of
births, marriages, and deaths. (An. Rep. S.B.H.. 7:xlv.)

99Jour. H. of Rep. State of Michigan, 8:61, 1870.

»Ubid., p. 24; Ibid., p. 110.

= f^SMS

Presacral Resection for the
Relief of Fain

By John C. Scully, B.S., M.D.

Menominee, Michigan

John C. Scully, M.D.

BS., University of Illinois; M.D.j Univer-
sity of Illinois College of Medicine, 1955.

Fellow of the American Med^caf Association,
Scholarship Member of the^ Mississippi Valley
Medical Society, and Junior Fellow of the
American College of Surgeons. Staff Mem-
ber of the Marinette General Hospital,
Marinette, Wis. Member of the Courtesy
Staff of the St. Joseph’s Hospital. Member,

Michigan State Medical Society.

■ The historical aspects of presacral resection
have been most thoroughly reviewed in a paper
by Walter D. Abbott, M.D., of Des Moines, Iowa.
As Dr. Abbott points out, this operation is not
new, since it was performed as early as 1898 by
Jaboulay. However, recently (1926-1940) there
have been numerous articles written about the
operation which indicate renewed interest in this

procedure. It has been recommended for a va-
riety of conditions, including Hirschsprung’s
congenital megalocolon, urinary vesical pain due
to tuberculosis, and intractable bladder infec-
tions, and dysmenorrhea of the so-called func-
tional type.

In some instances the results have been gratify-
ing, and in others the results have been indif-
ferent. Since this particular type of surgery
is in its comparatively early phase, I believe that
any contribution to our present knowledge, no
matter how minor, may be of some value.

Resection of the superior hypogastric plexus
for the relief of severe dysmenorrhea has been
endorsed by such competent surgeons as G. Cotte
of France, A. A. Davis of England, Walter D.
Abbott, Winchell McK.: Craig, and Nelson M.
Percy in this country, and with these recom-
mendations in mind, I have performed a pre-
sacral resection for the relief of pain presumably
due to a congenital uterine anomaly.

Case Report

The patient, M. G., an unmarried white female of
twenty-three, came under observation, complaining of
severe dysmenorrhea of ten years’ duration. Her men-
strual history was as follows :

History. — The menarche occurred at the age of thir-
teen, and from the onset her periods were markedly
irregular, varying from the usual twenty-eight days to
five or six months. During each period she had very
scant flow, using only one or two: pads daily. No
clots were passed at any time. Each period was as-
sociated with pain severe enough to inecessitate four
or five days of bed rest and the liberal use of
opiates. There was slight leukorrhea : between periods.
She denied intercourse or venereal infection. Her last
period prior to coming to the office was, as usual,
associated with very severe : dysmenorrhea, • low back
pains, and general malaise.

Examination. — Complete physical examination and the
usual laboratory procedures, including basal metabolic
rate, failed to reveal any abnormalities except of the
pelvic viscera. The introitus was virginal so that sat-
isfactory pelvic examination could be carried out only
under anesthesia. The patient consented to this exam-
ination and it was observed that the Bartholin and
Skenes glands were normal. The cervix was small
and pointed anteriorly. The external os was patent
and there was slight cervical erosion. The uterus was
apparently displaced to the left. It was anteflexed,
smooth, firm, and nulliparous. At the right utero-
cervical junction there was a mass protruding into the
right adnexa equal -in size to the uterus and appar-
ently connected to the uterus at the above location.

December, 1941

979

PRESACRAL RESECTION— SCULLY

This mass also seemed anteflexed. The left tube and
ovary were normal jn location, size, shape, consistency,
mobility, and attachments. On the right side a nor-
mal tube and ovary could also be palpated and were
not apparently displaced by the mass described. The
mesial attachment of the right tube could not definite-
ly be determined. The adnexa, apart from the above,
felt normal. A diagnosis of subserous uterine fibro-
myoma was made, and uterus didelphys unicollis was
also considered. As a conservative measure, in order
to correct the dysmenorrhea, the cervical canal was
dilated up to the caliber of a No. 22 French sound
at the time of examination. The patient had been
given appropriate glandular therapy prior to this exam-
ination and in spite of this no correction of her men-
strual irregularity had been effected.

The patient was advised to wait until another period
to determine if dilatation would afford relief. This
period occurred after 6 weeks from the onset of the
previous period and was in no way affected by the dila-
tation and the previous severe menstrual pain persisted.
Operation was then advised.

Operation. — At operation the patient was found to
have uterus didelphys unicollis. This particular anom-
aly appeared singular in that each of the uteri were
equally developed and situated in the same relative po-
sition. There was a peritoneal fold passing from the
sacrum anteriorly between the base of the two uteri
and merging anteriorly with the peritoneum covering
the posterior aspect of the bladder. Attached to the
lateral cornu of each uterus was an entirely normal
tube, ovary and broad and round ligament. There was
no other demonstrable lesion or abnormality in the pel-
vis.

Since pain was the primary complaint, there seemed
to be no reason to attack the anomaly surgically,
and the case presented an ideal indication for division
and resection of the presacral -nerve. This procedure
was carried out after the technique described by Drs.
N. M. Percy and H. P. Beatty with a modification sug-
gested by Dr. A. H. Curtis. The operation was com-
pleted by a radial cauterization of the cervix. The
patient made an uneventful recovery.

Convalescence .^lyurmg her convalescence the patient
had a menstrual flow lasting 6 days (normal for this
patient) and during this time was entirely free of
pain. Since the operation the patient has had 10 nor-
mal periods. She has faithfully communicated with
me at each period and assures me that she has no
pain at all with the catamenia and that the only dis-
comfort experienced has been the usual menstrual
malaise. Not anticipating amelioration of the irregular-
ity by the above surgical procedure, suitable glandular
therapy was instituted immediately after the patient
left the hospital. As previously stated, she has had
10 periods at about the usual 28-day intervals, and it
may be assumed that this therapy has helped to es-
tablish a normal menstrual cycle;

Discussion

Herein is presented a case of dysmenorrhea
associated with a uterine anomaly. The rela-
tionship between the anomaly and dysmenorrhea
is of course questionable, as many of these
anomalies are “silent.” However, in the absence
of other lesions of the pelvic viscera, and with
all conservative treatment of the accepted sort
having failed to relieve the pain, it must be as-
sumed that, in a measure, this patient had pain
as a result of the anomaly described, and de-
rived benefit from presacral resection.

Personal communications with surgeons else-
where reveal little or no experience with this
operation for relief of pain due to congenital
uterine anomalies, and it is hoped that this re-
port may stimulate an interest in this type of
surgical approach.

Summary and Conclusions

1. Presacral resection for pain presumably
caused by congenital uterine anomaly is reported.

2. This case of uterus didelphys unicollis ap-
pears to be unique in being bilaterally symmetri-
cal and because the tubes and ovaries, broad and
round ligaments were entirely normal and also
symmetrical.

3. Entire relief of severe dysmenorrhea pre-
sumably due to congenital uterine anomaly was
obtained by division and resection of the supe-
rior hypogastric plexus (presacral nerve).

Bibliography

Abbott, W. D. : Value of the resection of the presacral nerve
(superior hypogastric plexus). Jour. Iowa Med. Soc., 24:
607-610, (December) 1934.

Arey, L. B. : Developmental Anatomy, Anomalies of the Genital
Organs, p. 241.

Braasch, W. F. : Spastic irritable bladder controlled by sym-

pathectomy. Proceedings of the Staff of the Mayo Clinic,
393:9-27, 1934.

Cotte, G. : Resection du sympathetique pelvien. Gyne. et Obstet.,
23:233, 1931.

Cotte, G.: Resection du nerv presacre pour dysmenorrhea et
cystalgie. Persistance de cystalgie avec dysurie. Enervation
du col vesical guerison. Lyon Chir., 29:616-617, (Septem-
ber-October) 1932.

Cotte, G. : Treatment de la dysmenorrhea par la resection du
nerf presacre. Resultats eloignes des inervatives fontes.
Lyon Medical, 149:29-37, (January 10) 1932.

Craig, W. M. : Resection of the preasacral sympathetic nerves
(superior hypogastric plexus). Clinical applications. Surg.
Clin. North America, 14:673-683, (June) 1934.

Craig, W. M. : Discussion of the presentation by W. F. Braasch.
Proceedings of the Staff Meeting of the Mayo Clinic, 396:
27, 1934.

Davis, A. A.: Presacral nerve surgery, (superior hypogastric
plexus). Hunterian Lecture. Brit. RIed. Jour., pp. 1-6,
(July 7) 1934.

Davis, A. A.: Surgical anatomy of the presacral nerve. Jour.
Obst. and Gynec. British Empire, 410:942-952, 1934.

Davis, A. A.: The Presacral Nerve. Its Anatomy. Phvsiology.
Pathology, and Surgery. Philadelphia: W. B. Saunders

Company, 1930.

Elant. L. : The surgical anatomy of the so-called presacral nerve.
Surg., Gynec. and Obst., 55:581-589, 1932.

Meleney, F. L. : Hirschsprung’s disease. Ann. Surg., 103:1,
(January) 1936.

980

Jour. M.S.M.S.

THE ROENTGENOLOGIST— BOGART

Nesbit, and McLellen : Sympathectomy for the relief of vesical
spasm and pain resulting from intractable bladder infection.
Surg., Gyrlec. and Obst., 68:540-46, (February IS) 1939.
Percy, N. M., and Beatty, H. P. : Surgery of the superior hypo-
gastric plexus of the sympathetic nervous system. Surg.
Clin. North America, Chicago Number, (February) 1936.
Ranson, S. W. ; Anatomy of the Nervous System. Superior
Hypogastric Plexus. New York: C. Appleton & Company,

1931.

Williams, J. W. : Obstetrics. Development abnormalities of

the uterus. British Med. Jour. pp. 689-691, 1934.

Personal Communications

Bloomfield, J. H., M.D.
Browne, W. H., M.D.
Cleveland, David, M.D.
Crile, George, M.D.

Curtis, A. H., M.D.
Danforth, W. C., M.D.
Davis, Loyal, M.D.

DeLee, J. B., M.D.
Erdman, John F., M.D.
Falls, F. H., M.D.
Greenhill, Joseph P., M.D.
Heaney, N. Sproat, M.D.
Hillis, David S., M.D.

Irving, Fredrick C., M.D,
Jackson, James A., M.D.
Lahey, Frank A., M.D.
Lash, A. F., M.D.
Masson, James C., M.D.
Meleney, F. L., M.D.
Nadeau, Oscar E., M.D.
Peet, Max Minor, M.D.
Pemberton, F. A., M.D.
Schwartz, George, M.D.
Watson, B. P., M.D.
Whipple, Allen O., M.D.

The Relationship of the Roent-
genologist to the Physician
and Snrgenn*

By Leon M. Bogart, M.D.

FUnt, Michigan

Leon M. Bogart, M.D.

M.D., Chicago College of Medicine and Sur-
gery, 1913; Chief of Surgery at St. Joseph
Hospital, Flint, Michigan; president-elect of
Flint A,cademy of Surgery; member, Michigan
State Medical Society; member, American As-
sociation for the Study of Goiter.

■ Roentgen, when he discovered the x-ray in
1895, uncovered a hornet’s nest. The doctor,
secure in his fringe of scientific terms, was too
close to the aura of empiricism to be jolted out
of his toppling Galenic conception. Keen’s
“Surgery,” published in the latter part of the 19th
century, spoke of cholecystitis as being caused by
tight lacing, but spoke very little of the disease
itself. Tait, in the late seventies of the 19th
century, doubted the wisdom of asepsis in sur-

*Read first March 18, 1939, before the Michigan State Roent-
genological Society, Hurley Hospital, Flint, Michigan.

Read again by request May 21, 1941, before the Third Annual
Fracture Clinic, given under the auspices of the Regional Frac-
ture Committee of the American College of Surgeons and the
Genesee County Medical Society, Hurley Hospital, Flint, Michi-
gan.

December, 1941

gery. Osier’s edition of 1905 has little reference
to x-rays. Surgeons abroad early recognized its
value, for in 1896 reports of surgical pathological
lesions were described with x-ray findings. In
1907, in Dr. DaCosta’s “Surgery,” little reference
was made to x-ray in the text, but in a discussion
rather extensive mention is made of possibilities,
also the advisability of mixing bismuth with food
to visualize the gastro-intestinal tract was dis-
cussed.

The mysterious ray, piercing the depth of tis-
sues and recording different density, not only
brought out the silhouette of bone, but empha-
sized the necessity of physical comparison of
shadows in physiology as well as pathology.
When Cannon and Williams first gave an opaque
meal, the innermost secrets of eternally covered
unknowns were blasted open to the curious gaze
of the delving scientists, as though it were the
secrets of the solid undercore of the earth made
available for scientific observation. When early
reports of x-ray bums and x-ray epithelioma
became known, the destruction of the tissues be-
came a hunting ground for the investigator and
research worker, to turn the flood of destruc-
tion to the nihilist cell — the cancer cell.

From the little flicker of the first gas jet vac-
uum tube emitting the unknown ray that man
made and controlled, grew the precise tabulator of
pathological processes of today.

Friedenwald, many years ago, brought to the
attention of the roentgenologist the irregularity of
the mucosa in gastric ulcer, and now this sign is
coming into prominence with the improvement
of the technique of rugae visualization. The lab-
oratory evaluation of gastric ulcer diagnosis has
been greatly superseded by the x-ray findings, but
here the surgeon must remember that often one
is apt to read into the plate nonexistent pathol-

ofly-

It is indeed a far cry from the full hour
exposure required in the early days of x-ray to
the present split second exposure with its exact
delineation and clarity. The art of physical
diagnosis and great personal error has largely
given way to the penetrating ray. Yet we, as
physicians and surgeons, by relying too much
upon the trained interpretation of the x-ray
findings, must not lose sight that the personal
equation is not to be discounted, for the radiol-
ogists differ between themselves just as frequent-

981-

THE ROENTGENOLOGIST— BOGART

ly as the physicians or surgeons. The plate is
inanimate — the human mind reads its signs.

One of the most useful branches of radio-
logic technic, and one probably requiring most
judgment, fluoroscopy has lent itself to be the
most blatant instrument of the charlatan.
Newspaper and radio advertisements are full
of misconceptions of fluoroscopic values and
the public is misled as to its possibilities. All
of us, I am sure, deplore its misuse and hope
the public can be educated to its limitations.

The importance of the x-ray in the diagnosis
of tuberculosis and as a check-up of its thera-
peutics has been proved invaluable. The detection
of metastases and emboli is another chapter of
scientific detection greater than fiction. Of course
the oldest service for which x-ray was used was
the diagnosis of bone pathology and perhaps it is
the one fraught with the most danger to the
surgeon, because of the perfection expected in
the treatment of fractures. The measurements
and comparisons which the student of yore was
taught are entirely disregarded by him now, yet
hr my judgment not to be discarded, for if
length, alignment and natural contour be taken
in consideration, especially in the young, seem-
ing faulty position of bone fragments are still
molded into position as in the days antedating
the x-ray. It is noteworthy that the attending
physician only too often expects the roentgen-
ologist to be the all-round specialist of interpre-
tation, a glorified scientific soothsayer, which, of
course, is flattering but leads to a yoke of de-
pendence.

The flat plate herring-bone appearance of
acute ileus or the telltale gas bubble in a
subphrenic abscess, with the characteristic
elevation of the diaphragm admit of no dispute
in the diagnosis if taken iii conjunction with
the history and clinical course. The patho-
gnomonic appearance of pencil-like narrowing
in regional ileitis and many other positive
findings of the x-ray form the bulwark of the
diagnostic aids to the surgeon. Lesions of the
large bowel or the stomach need more than
ordinary acumen to diagpiose unless definite
pathologic size has developed. The surgeon
expects too much when he looks to the roent-
genologist to find the above-mentioned lesions

in the initial stages, and negative findings
should not deter the surgeon from proceeding
with an exploratory operation. It is desirable
to be able to localize early stages which do not
show gross changes, and careful and minute
study, will, in many instances, detect changes
in the physiologic contour brought about by
the microscopic changes. The contrast ob-
tained by forced gas distention of the bowel
lumen has made many early lesions possible
of detection. Even the etiological factor can
be told within a certain degree of accuracy, due
to the predilection of specific pathologic le-
sions for certain parts of the alimentary tract
or bones.

We have to recognize that frequency of x-ray
determinations does something to the end of the
fractured bones, which retards the formation
of callus. X-ray signs of bone dissolution, de-
struction and regeneration require knowledge of
normal anatomy and physiology first, and se-
quence as well as regional pathology. Early
pathologic changes become apparent to the skilled
roentgenologist, as an irritable duodenum or
pylorus may be recognized before full clinical
symptoms of gastric ulcer appear, or an im-
pending Suedeck’s syndrome may be prognosti-
cated by the early and persistent atrophy of bone.

To Rowntree and Abel, Cole and Graham,
Swick and others, we owe the demonstration of
the selective absorption of radio-opaque dyes
given orally or intravenously and its use mag-
nificently demonstrated in their widespread ap-
plication. It is not necessary to remind you of
opaque substances introduced through the ureters
and per urethra into the bladder and the intro-
duction of an opaque solution into the bladder
for determination of bladder malignancies, or as
the author lately used it in determination of
ruptured urinary bladder.^ The use of radio-
opaque oils or dyes to visualize spinal lesions and
vascular pathology has been widely reported,
requiring great skill and cooperation of roent-
genologist and surgeon. The introduction of gas
for ventriculograms also needs the teamwork
mentioned above, and the use of ethylene in-
stead of air seems to be gaining favor. The re-
moval of the opaque dyes or oils used is of con-
cern to both roentgenologist and surgeon, and is
of great importance to the patient. The surgeon

982

Jour. M.S.M.S.

PHYSIOLOGY OF THE NOSE— HEETDERKS

must not forget that microscopic changes do
not manifest themselves in an x-ray plate ; there-
fore, osteomyelitis, malignancies, or early bone
deposits are not recognized in the early initial
stages, and when negative to x-ray must not be
dismissed as absent. Localization of foreign
bodies on the plate does not always spell a spec-
tacular removal, for I admit many difficulties
that I had to cope with, even after excellent x-ray
localization.

I can only allude to the brilliant chapter writ-
ten by roentgenology in the field of therapeutics,
especially deep x-ray in pre- and postoperative
care of malignancies, as well as the direct at-
tack of the lesion. Many enthusiastic reports in
the treatment of acute regional infections have
come to the fore, especially in acute postopera-
tive parotitis or thrombophlebitis.

Controlled injection of radio-opaque media into
fistulous tracts as well as the visualization of the
biliary tract and detection of hidden duct stones
by means of the x-ray on the operating table
is being put to more frequent use.

The physician and surgeon must educate the
laity that a roentgenologist is not a photographer
of structures. We know that the x-ray plate is
a record of the normal and abnormal anatomy
and physiology ; its deciphering requires skill and
training, requiring a great deal of time and
perseverance.

Baetzer and Waters^ state that the roentgenol-
ogist has four inseparable friends, the anatomist,
pathologist, internist and surgeon, and I wish
to add a fifth one, the physiologist. With them
his work rises or falls. The physician and the
surgeon should not shed their responsibility and
expect the roentgenologist to make the diagnosis
for them. The roentgenologist should be con-
sidered a highly skilled physician with whom his
colleagues cooperate and coordinate as one of the
important highways to reach the destination of a
workable diagnosis and possible cure, and not
the sun around which the medical and surgical
diagnosis revolves.

References

1. Baetzer and Waters: Injuries and Diseases of the Bones

and Joints. New York: Paul B. Hoeber, 1927.

2. Bogart, L. M. : Rupture of the urinary bladder. Amer.
Jour. Surg., 23:442, (March) 1934.

December, 1941

The Physiology of the IVose*

By Dewey R. Heetderks, M.D.

Grand Rapids, Michigan

Dewey R. Heetderks, M.D.

A.B., University of Michigan, 1918. M.D.,
University of Michigan, 1922. M.Sc. in Oto-
laryngology, University of Minnesota Post-
graduate School, 1927. Fellow of the Ameri-
can College of Surgeons. Certified by the
American Board of Otolaryngology. Member,
American Academy of Ophthalmology and Oto-
laryngology, Western Michigan Trtological So-
ciety, Michigan State Medical Society.

■ It is important that the rhinologist be familiar
with reactions of the normal nasal mucous
membrane to the various environmental condi-
tions so that he may be better able to evaluate
symptoms of which a patient may complain.
Many persons in robust health complain of symp-
toms referable to the upper respiratory tract
which on final analysis may be explained on a
physiologic basis.

In 1926, the writer undertook a study^ to de-
termine the nature and extent of reactions of
normal nasal mucous membrane. Throughout
this study persons with apparently normal noses
were observed. Ten persons in each of the first
six decades of life were selected. The nasal
membrane in every case was carefully observed
in each of the atmospheric conditions so that a
total of 240 observations were made. In select-
ing the conditions under which to observe the
reactions of the nasal mucous membrane, an at-
tempt was made to supply every possible relation-
ship of temperature and humidity of the atmos-
phere which is ordinarily encountered.

Some of the results noted were as follows :

In moderate outside air with a temperature
of from 13 to 18“ C. and relative humidity of
from 50 to 60 per cent, every subject showed
slight swelling of the turbinates and the nasal
secretions were scantily distributed over the
mucous membrane. There was a correspond-
ingly large breathing space. Apparently the
least amount of work is done by the nose in
such warm, moist air. The opposite extreme
was observed in cold, damp air. In warm, but
very dry air, the turbinates were considerably
swollen though less than in cold damp at-
mospheres. It was thought the swollen tur-

*Presented at the annual meeting of the Michigan State Medi-
cal Society, Detroit, September 26, 1940.

983

PHYSIOLOGY OF THE NOSE— HEETDERKS

binates probably act as an adaptive reflex
mechanism in preventing too free admission
of the warm dry air.

When subjected to varying environmental con-
ditions, the nasal mucous membrane showed a
great variation in the rapidity of response in dif-
ferent individuals. In general, adolescents showed
the most active mucous membrane. From ado-
lescence until old age there was a progressive re-
tardation in the response of this membrane.

Cycle of Reaction

In 1923, Lillie^^ called attention to the idea of
a cycle of reaction in the nose. In 80 per cent of
the subjects, this cycle was apparent, that is, the
turbinates of one side of the nose were filling
while those on the opposite side were throwing
off secretion. This cycle did not always take
place to the same extent. Cold, damp atmosphere
prompted more pronounced changes than the less
provocative environments. These cycles of re-
action occurred over varying lengths of time
ranging from 15 minutes to two hours.

Subjects were also examined in recumbent pos-
tures because of the common complaint of nasal
obstruction on the dependent side at night. The
lower side nearly filled or filled completely in
every case in an average time of twenty-five
minutes.

The nasal secretions seemed to bear a definite
relationship to the congestion of the turbinal
structures, that is, being more copious with swell-
ing of the turbinates and vice versa. During ado-
lescence, an age of physiologic activity, the nasal
secretions were found to be abundant. In old age
and advanced middle life, the secretions were
much reduced in amount.

In about 10 per cent of the cases, there was
definite debris about the fibrissae of the nasal
vestibules, and in at least half of the nasal cavi-
ties, the secretions contained fine debris. Every
subject examined in the lower temperatures
showed moisture in the vestibules. This moisture
was never observed in warmer air and could be
produced by exposing the subject to cold air for
five minutes. The logical explanation of this fact
is that cooling the expired air lowers its satura-
tion point and some of its moisture must be
condensed.

The conclusions reached from this study were:

1. The nose has three definite functions

other than olfaction; to warm, moisten and fil-
ter the inspired air.

2. The mechanism is the mucous mem-
brane, the available surface of which is in-
creased by turbinal turgescence.

3. The nose reacts differently under various
environmental conditions and at different ages.

4. Most noses show a fairly definite cycle of
reaction.

5. The following symptoms need not be due
to pathologic conditions and can readily be
explained as physiologic responses ; nasal ob-
struction in hot dry rooms; the watery nasal
discharge in cold weather and during adoles-
cence ; the dropping back into the throat of se-
cretions often containing debris, and obstruc-
tion of the nose on the dependent side.

Functions

Since making this study, many enlightening
contributions have appeared in the literature on
the function of the nose and its mechanism.
Time permits a rather brief review of only some
of these. Humidification and warming of the
inspired air are important functions of the nose.^°
Humidification is essential to the processes of
alveolar respiration. Light is also essential to
the maintenance of the cilia and their protective
mucous blanket. Air laden with dust or con-
taining bacteria is cleansed to a large extent in
the nasal passages.^ Hilding’s® studies on drain-
age of nasal mucus will be referred to later.

Lehmann devised a simple but ingenious tech-
nic for measuring nasal filtering efficiency. He
found the median average of nasal efficiency 46
per cent for normals and 27 per cent for sili-
cotics. Tourangeau and Drinker^® found efficien-
cies lower than those reported by Lehmann.
They found practically no efficiency over 30 per
cent and inferred from this that the dust filtering
efficiency of the nose is too low to be of import-
ance in preventing fine dust from reaching the
lungs.

Lehmanffi^ did some interesting work to show
the significance of dust filtering efficiency in the
development of silicosis. This dust absorptive
ability of the nose he found to vary widely.
When low, the subject could work but few years
if he were to avoid silicosis. When high, the
worker seldom gets the disease even though em-
ployed many years in this dusty environment.

984

Jour. M.S.M.S.

PHYSIOLOGY OF THE NOSE— HEETDERKS

Mucus Secretions

In recent years many interesting investigations
have been made on the mucous secretions of the
nose. Its source is the goblet cells and mucous
glands of the nasal membrane. With these two
type of glands in operation, Leasure^^ believes
quite a variety possible in the quality of the nasal
secretions present according to which type of
gland is more active.

Tweedie,^'^ Mittemeier,^^ Buhrmester^ and
Hilding'^ have made important contributions in
regard to the pH of nasal mucus. Their findings
have varied, some reporting the pH to be acid
and others alkaline, with resulting confusion. It
remained for Peterson^® to clear up these discrep-
ancies this past spring- He studied the nasal
mucus in relation to environmental change and
to other changes occurring in the organism.
He pointed out that single readings taken at
different times mean little or nothing. He
therefore carried out this observation in day-to-
day fashion on a number of subjects.

The pH of the normal membrane was changing
constantly. They found that there is a distinct
diurnal rhythm, there is a distinct rhythm asso-
ciated with gastro-intestinal activity correspond-
ing to the intake of major meals and there is a
meteorological rhythm. PH curves were charted
and below each the curve for the bacterial count
of a circumscribed area of the mucous mem-
brane. There was a constant change in the bac-
terial population as it fluctuates with the physio-
logical state of the mucous membrane. For ex-
ample, when weather gets colder, the pH in-
creases ; that is, the mucus becomes more alka-
line and the bacterial count rises sharply. When
weather gets warmer, the reverse takes place in-
dicating that acid mucus inhibits the growth of
organisms^’^® (Fig. 1).

The destruction and removal of bacteria from
the nose is not entirely mechanical, but is also
antiseptic. This work is done by an enzyme nor-
mally present in the nasal mucus which is a
powerful antiseptic.® Hilding® found this lytic
power is reduced in the first two days of a cold.

Drainage

The drainage of nasal mucus was studied by
Hilding.® Because of its importance, some of his
findings will be briefly reviewed. The film of
nasal mucus extends like a continuous mem-
brane over all the nasal surface. This film is in

continuous motion throughout its extent. The
rate of motion varies in different regions. The
greatest rate is generally found in those areas
best protected from the force of the inspired air,
that is, in the meati. The mucous film of blanket

eilka/i'ne, mucos and rising Lactenal count
foUoH lack of rest j over- eatinij ceJj

weather.

Fig. 1.

is motivated by four forces: (1) by the ciliary
activity directly, (2) by gravity, (3) by traction
due to cilia, and (4) by traction from the
pharynx as in swallowing.

The mucous membrane of the anterior one-
third of the nose is relatively inactive due to
lack of cilia. The drainage of mucus from this
area is different from the rest of the nose.
Drainage is slow and is accomplished by traction
of the secretions on the inactive membrane by
ciliary movements in the adjacent active mem-
brane. In other words, it is dragged as a net.
Because of the slow drainage in this area, dust
and cosmetics are often seen whereas the re-
mainder of the nose is clean. At least an hour is
required to remove particles from the anterior
one-third, but only five to ten minutes will suf-
fice for the posterior two-thirds. Hilding in a
single sentence gives a rather comprehensive pic-
ture of the mucous film, “the layer of secretion
covering the surfaces is at once a protective blan-
ket and endless conveyor, a medium for ciliary
action, an impervious barrier to bacteria and a
trap for them, a drag-net to sweep clean the non-

December, 1941

985

PHYSIOLOGY OF THE NOSE— HEETDERKS

ciliary spots, a humidifier, a dilfusion medium
and a lubricant” (Fig. 2).

The cilia within the nose are the chief agent
in maintaining the normal clearance of the nasal
cavity. All epithelia of the nose are modifications

including their secretory and ciliary activity is
regulated and controlled through the autonomic
and afferent nerves.^^ It is interesting to note
that the cavernous or erectile tissue in the nasal
mucosa does not always conform to the vascular

Sphenoid sinus

Eustachian tube

Fig. 2.

of one type, that is, ciliated epithelium. Modifica-
tions are caused by varying degrees of exposure
to in- and out-flowing air.®

Lucas and Douglas^® found that the so-called
mucous film or sheet is composed of two parts :
an outer stratum of viscid mucus which rests on
the tips of the moving cilia and an inner fluid
layer of low viscosity, which forms a suitable
medium for the vibrating cilia. The inner layer
flows with the vibrating of the cilia, but the outer
viscid layer may or may not respond to the beat-
ing of the cilia against its under surface.^®

Ciliary activity is autonomic with the cell, it
may be a sympathetic nerve influence, but is not
proved. It varies some with temperature, the op-
timum being between 28 and 33 Although
the cilia serve as a first line of defense they must
not be regarded as weak and frail as pointed out
by Heine.® A single dose of unfiltered roentgen
ray of eight erythemas is the maximum for the
skin of man. However, the evidence points to-
ward the fact that these frail-appearing cilia will
stand three times such a dose with impunity.

The functional state of the mucous membrane

state of the adjacent mucous membrane, although
its blood vessels and those of the adjacent mu-
cous membranes are innervated by the same
nerves. Various investigators,^® particularly
Sternberg, have called attention to the fact that
engorgement of the cavernous tissue frequently
takes place while the mucous membrane is rela-
tively ischemic and that not infrequently it con-
tracts while the mucous membrane is markedly
hyperemic. The explanation lies in the fact that
the capillary bed in cavernous tissue is inter-
posed between veins whereas the capillary bed in
other parts of the nasal mucosa is interposed be-
tween arteries and veins. In view of this ar-
rangement, reflex stimulation which elicits vaso-
constricture in the nasal mucosa might prevent
emptying of the capillary bed in the cavernous
tissue by contraction of veins into which it drains.

Clinical observations as well as medical litera-
ture forces one to recognize the interrelationship
between the nose and the rest of the body. This
was pointed out in Peterson’s findings regarding
the rhythm of the pH of nasal mucus associated
with gastro-intestinal activity. The nasogenital

Jour. M.S.M.S.

986

PHYSIOLOGY OF THE NOSE— HEETDERKS

relationship has also been definitely established.
Mortimer and his associates found that the nasal
mucous membrane of pregnant women showed
increased redness and swelling in the later stages
of pregnancy. Mackenzie and subsequent ob-
servers have confirmed the view that in a certain
percentage of normal women there is hyperemia
and swelling of nasal mucosa during menstrua-
tion. Many reports have been made associating
nasal stuffiness and sneezing with acts of copu-
lation and sexual excitation.^®

Effect of Chilling

Some very important studies have been made
on the effects of chilling of body surfaces. Ex-
periments were made with fans, cold HgO and ice
with fairly uniform results.

Taylor and Dyrenforth®^ have shown that cold
water takes heat from the body twenty-seven
times faster than air. Individuals in cold H.^O
without exercise may manifest a drop of over
10 degree F. in the nose, often with consequent
colds.

Visscher and Spiesman^^ point out that a
change in temperature of only two or three de-
grees in the mucous membrane of the nose means
a marked alteration in blood flow that produces
such a fall of temperature.

A fall of even one or two degrees may mean
that there is an absolute anemia of the mucosa
and consequently a lack of oxygen which is ex-
tremely favorable for the growth of pathogenic
organisms. The cardinal factor in avoiding up-
per respiratory infection is the maintenance of a
constant average temperature in the nose because
any considerable degree of deviation from this
average for appreciable periods of time will re-
sult in morbid changes.

Undritz and Sassassow®® also studied the effect
on the nasal mucous membrane resulting from
cold applied to the skin. They concluded that the
cooling of the nasal membrane depended not only
on external cold applied, but also on the consti-
tutional make-up. The decrease in nasal tempera-
ture lasts much longer than the cold applied ex-
ternally, but this time factor was subject to great
variation.

The interactions between the splanchnic and
peripheral circulation serves to explain why the
nasal mucous membrane becomes anemic during
these experiments. The autonomic status of the
circulation of the abdominal and pelvic organs is
opposed to that of the extraperitoneal organs and

tissues. As a result of this relationship, the
autonomic status of the respiratory mucous mem-
brane corresponds to that of the skin. If the
body is exposed to low temperatures, particularly
in the absence of muscular activity, the skin be-
comes relatively ischemic owing to peripheral
vasoconstricture. Since the autonomic orientation
of the respiratory mucous membrane corresponds
to that of the skin, they also become ischemic.

Summary

In summarizing, one is impressed with the
ingenious and complex mechanism of the nose.
This mechanism functions in ordinary environ-
ments with remarkable efficiency. It is, however,
affected adversely by any form of cold applied
to the body, especially when not exercising, a
consideration most important in the prevention
of colds. The vasomotor activity of the nose
varies not only with different environments and
emotional factors, but also with the age and con-
stitutional make-up of the individual.

References

1.

2.

3.

4.

5.

7.

8.
9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

Buhrmester, C. : Content and viscosity of nasal secretion.

Ann. Otol. Rhinol. and Laryng., 42:1040, 1933.

FabricanC Noah: Personal communication.

Fenton, K. A., and Larsell, O.: The defense mechanisms of
the upper respiratory tract. Ann. Otol., 46:303, (June)
1937.

Heetderks, D. R. : Observations on the reactions of normal
mucous membrane. Am. Jour. Med. Sci., p. 231, (August)
1927.

Heine, L. H. : The effect of radiation upon ciliated epi-

thelium. Ann. Otol. Rhinol and Laryng., 45:60, (March)
1936.

Hilding, A. : The physiology of drainage of nasal mucus.

Arch. Otol., 15:92, (Jan.) 1932.

Hilding, A.: Note on some changes in the hydrogen ion

concentration of nasal mucus. Ann. Otol. Rhinol. and
Laryng., 43:47, (March) 1934.

Hilding, A.: Studies on the common cold and nasal

physiology. Trans. Am. Laryng. Assoc., 56:253. 1934.
Hilding, A.: Changes in the lysozyme content of the nasal
mucus during colds. Arch. Otol., 20:38, (July) 1934.
Kuntz: The autonomic nervous system. Jour. A.M.A.,

107:334, (Aug. 11 1936.

Larsell, O. and Fenton, R. A.: Sympathetic innervation of
the nose. Arch. Otol., 24:687, (Dec.) 1936.

Leasure, J. K. : The secretion of the nasal mucous mem-
brane. Trans. Ind. Acad. Ophthal. and Otol., p. 13, (Dec.
12) 1934.

Lehmann, G. : Significance of dust filtering efficiency_ of

human nose in the development of silicosis. Arbeitsphysiol.,

9:206-216, 1936.

Lillie, H. I. : Personal communication.

Lucas, A. M., and Douglas, L. C. : Principles underlying

ciliary activity in the respiratory tract. Arch. Otol., 20:518,
(Oct.) 1934.

Lucas, A. M., and Douglas, L. C. : Principles underlying

ciliary activity in the respiratory tract. Arch. Otol., 21 :285,
(March) 1935.

Mittemeier: Content and viscosity of nasal secretion. Ann.
Otol. Rhinol. and Laryng., 42:1040, 1933.

Petersen, W. F. : Human organic reactions to weather

changes. Bull. Am. Meteorol. Soc., 21:170-175, (May) 1940.
Petersen, W. F. : Personal communication.

Proetz, A.: Some studies on nasal function. Ann. Otol.

Rhinol. and Laryng., 41:125, 1932.

Proetz, A.: Applied physiology of the nose and accessory

nasal sinuses. Am. Jour. Surg., 42:190, (October) 1938.
Proetz, A. W. : Effect of temperature on nasal cilia. Arch.
Otol., 19:607, (May) 1934.

Rosen, S.: The nasogenital relationship. Arch. Otol., 28:

556, (Oct.) 1938.

Soiesman. I. G. : Vasomotor reactions. Arch. Otol., 17:829,
(Tune) 1933.

Tavlor and Dyrenforth: (Thilling of body surfaces. Jour.

A.M.A., 111:1744 (Nov. 5). 1938.

Tourangeau, F. J., and Drinker, P. : The dust filtering ef-
ficiency of the human nose. Jour. Indust. Hyg. and Toxi-
col., 19:53-57, (Jan.) 1937.

December, 1941

987

BLACKWATER FEVER— HOLM

27. Tweedie, A. R. : Nasal flora and reaction of the nasal

mucus. Jour. Laryng. and Otol., 49:586, 1934.

28. Undritz and Sassassow: Reflex changes of temperature of

nasal mucous membrane due to local applications of cold.
Ztschr. f. Hals, Nasen u. Ohrenh., 32:300, 1932.

[V|SMS

The Successful Use of
Sulfauilamide iu the Treatmeut
of Blackwater Fever

By Benton Holm, M.D.

Cadillac, Michigan

Benton Holm, M.D.

A.B., Augustana College, 1927. M.D.,

Northwestern University, 1932. Member Staff,

Mercy Hospital, Cadillac. Member, Michigan
State Medical Society.

■ Blackwater fever is not an unusual condi-
tion in the malarial districts, but to encounter
a case in Northern Michigan, however, is quite
surprising. This case presented several phases
which seem unusual enough to warrant this re-
port. Search of the medical literature reveals no
reported cases which have been treated with the
sulfanilamide group. Several reports on the use
of these drugs in ordinary malaria have been
recorded in the past three years. Hill and Good-
win have reported one hundred cases of malaria
treated with sulfanilamide with excellent results.

Blackwater fever or malarial hemoglobinuria
is generally considered to be one clinical manifes-
tation or malignant form of malaria. Most au-
thorities believe that the estivo-autumnal parasite
is usually present. In this condition the red cells
are dissolved or hemolyzed, and the hemoglobin
is liberated into the blood stream. The destruc-
tion of red blood cells may be so extensive that
the liver, spleen, and other organs that normally
take care of the hemoglobin from worn-out or
dead cells are unable to do so and the excess
amount of hemoglobin is excreted by the kidneys
in such quantities that the color of the urine be-
comes red, and may be in such quantity as to
give the urine a black color — hence the term
“blackwater.”

The onset of blackwater fever generally be-
gins with a chill, followed by a high temperature,
great prostration, thirst, vomiting, abdominal dis-
tress, aching loins, and great tenderness over the

acutely enlarged liver and spleen. The patient
rapidly becomes jaundiced, and the urine that
is passed varies in color from red to black. The
red count and hemoglobin may drop rapidly to
very low levels. Death occurs in about twenty
per cent of the cases. Anuria is the most dreaded
complication and the outcome is usually fatal.

No specific treatment has been proved to be
of value. Quinine is usually withheld or given
with caution as it may contribute to the hemol-
ysis. Rest, good nursing care, parenteral fluids,
and blood transfusions all are of value. Many
drugs of questionable value are advised, such as
— alkalies, adrenalin, caffeine sodium benzoate,
atabrine, snake venom and neo-arsphenamine. No
reports of the previous use of sulfanilamide have
been found.

Case Report

E. S., a thirty-six-year-old white woman, was ad-
mitted to Mercy Hospital, Cadillac, Michigan, on No-
vember 28, 1937, complaining of chills, fever, and pas-
sage of black urine. She had been a foreign missionary
for eight years, going to French Equatorial Africa
in 1929. She returned to the United States in 1931
for one year. From there she had gone to Paris,
France, for a year’s study. She had returned to Africa
in 1934, remaining there until June, 1937, when she
came back to America.

She had the first attack of malaria in Africa in
1930. She had taken 5 grains of quinine daily upon
arrival in Africa and had continued quite faithfully.
However, after neglecting this for a week she developed
chills and fever in 1930. This lasted three days and
was easily controlled with quinine. In December, 1934,
she had another slight attack which responded quickly
to quinine. One year later she had another mild attack
of malaria. While on the boat returning to America
in June, 1937, she again had chills and fever. Follow-
ing this she took quinine, five grains daily, more or
less irregularly for two months.

Other than these attacks of chills and fever, the
patient noted no symptoms until three months before
admittance, when she developed tinnitus and weakness.
She was also told by her friends that they had noted
a gradually increasing pallor of her skin.

In August, 1937, she had an attack of pain in the
lower abdomen for which she was kept in bed for two
months.

The present attack began on November 22, 1937,
six days previous to admittance, with slight chills and
fever, which persisted daily until November 27, 1937,
when she had a severe chill and first noticed the pass-
ing of black urine. This had cleared up but the next
day she had another chill with a temperature of 105 de-
grees and again passed dark urine. On admittance to
the hospital that evening she had another chill and

Jour. M.S.M.S.

988

BLACK^^■ATER FEVER— HOLM

complained of nausea and vomiting, extreme thirst,
and pain in the right upper abdominal quadrant.

Inventory by systems revealed little of significance.
There was no history of other previous illnesses. Men-
struation had begun at sixteen. Her periods had been
regular, occurring every four weeks and being mod-
erate in amount until ten months ago, when they be-
came profuse and occurred every three weeks with
pain in the lower abdomen during menstruation.

Physical Exatnination. — On admittance examination
revealed a rather thin, white woman of about thirty-
five years of age, with marked pallor and a pale lemon
yellow color of the skin and sclerse. She was evi-
dently acutely ill although well oriented and cooper-
ative.

Temperature 106.4 degrees. Pulse 110. Respirations
28. Her pupils reacted normally. Sclerae were icteric.
The mucous membranes and conjunctivae were verj’
pale, without petechiae. Mouth was normal. There
was no thyroid enlargement. Her chest was clear and
resonant throughout. The heart borders were well
within normal limits but a systolic murmur was present
at the apex and over the pulmonic area. Rhythm
was regular, rate 110. The abdomen was soft and
flat. The liver edge was felt one hand’s breadth below
the costal margin, was very tender, not nodular. The
spleen was markedly enlarged and extended five inches
below the left costal margin. There were no other
masses or tenderness, or costovertebral tenderness.
Pelvic examination revealed a nulliparous introitus,
hymen intact ; cervix pointing down and anteriorly
was freely movable. No adnexal enlargement or ten-
derness. Neurological examination was negative.

Laboratory examinations of the blood on admittance
were as follows : red blood count 890,000, white blood
count, 4,300, hemoglobin 25. Smear of blood showed
no malarial parasites. A differential count showed
juveniles 4, stab 36, segmented 24, small l3-mphoc}'tes
3, large lymphocjhes 10, monocytes 19, degenerated cells
1, irregular Rmphocytes 3. Red blood cells were swol-
len, with a few microcytes, a few hj-perchromic and
hj’pochromic cells. The icterus index was 100. V an-
denberg reaction was indirect. Blood culture was neg-
ative.

Course in Hospital (first three weeks). — Twelve
hours after admittance the temperature went up to
108.4 degrees axillary, but came domi to 99 and 100
degrees for the following three days. Then she again
had rigors with high fever nearly every day. The
urine remained black. The red count was brought up
by frequent blood transfusions but soon fell again to
extremely low levels. Patient complained of abdominal
distress, nausea, weakness, and palpitation. Delirium
was quite marked after the severe rigors. On De-
cember 17, 1937, she appeared to be d^dng. She was
cyanotic, comatose and pulseless at times. Her face
and hands were edematous.

Summary of Laboratory Work. — Blood Kahn was
negative. Icterus index 100. Agglutination tests for
typhoid, paratyphoid and undulant fever were negative.

Date

Red Blood
Cells

Hemo-

globin

%

Highest

Tempera-

ture

Chills

Color of
Urine

11-28-37

890,000

25

108.4

X

black

11-30-37

1,300,000

28

101.0

amber

12- 1-37

970,000

26

101.8

amber

12- 2-37

1,840,000

32

103.8

X

black

12- 3-37

1,550,000

30

103.8

X

dark red

12- 4-37

1,640,000

38

103.2

X

black

12- 6-37

1,310,000

32

106.2

X

black

12- 7-37

1,290,000

25

105.8

X

pale red

12- 9-37

1,200,000

21

102.0

straw

12-11-37

1,330,000

25

103.8

X

amber

12-13-37

1,720,000

34

104.8

XXX

black

12-14-37

1,260,000

30

105.8

XX

red

12-16-37

870,000

16

102.8

black

12-18-37

650,000

10

101.8

red

12-18-37

Prontosil

started

12-20-37

610,000

10—

99.8

red

12-22-37

860,000

10 -f

99.6

red

12-24-37

1,530,000

35

100.0

amber

12-26-37

1,790,000

37

99.2

straw

12-28-37

1,630,000

38

98.6

straw

12-30-37

1,850,000

40

98.6

straw

1- 4-38

2,280,000

42

98.6

straw

1- 8-38

2,340,000

46

98.6

straw

1-12-38

2,000,000

47

99.0

straw

1-24-38

2,810,000

50

98.8

straw

1-31-38

3,070,000

53

98.0

straw

2-13-38

4,080,000

60

98.0

straw

2-25-38

4,100,000

64

98.0

straw

Daily blood smears were negative for malarial para-
sites except on November 28, 1937, and on December
7, 1937, when estivo-autumnal organisms were found.
Blood cultures were repeatedly negative. Blood sugar
was 88 milligrams per 100 cubic centimeters. Blood
non-protein nitrogen was 53 milligrams per 100 cubic
centimeters. The feces were repeatedly negative for ova
or parasites. The urine was consistently reddish purple
or black in color. The red count and hemoglobin are
recorded in Table I. The white count varied from 2,000
to 6,000.

December, 1941.

989

BLACKWATER FEVER— HOLM

Summary of Treatment (first three weeks). — Two
thousand to four thousand cubic centimeters of in-
travenous saline and glucose were given daily. On
November 30, 1937, atabrine was started and 1.5 grains
given three times a day for fifteen doses. On E>e-
cember 2, snake venom in increasing doses was given
daily. Intramuscular liver extract and ferrous sulfate
with vitamin B were given daily. Cafeine sodium ben-
zoate, 7.5 grains twice daily, and adrenalin m. X when-
ever needed for sixteen days. Quinine, 5 grains three
times daily, was started on December 11, but dis-
continued after two days. Six thousand cubic centi-
meters of citrated blood from thirteen donors were
given at intervals during the first three weeks. Cold
wet packs were used for hyperthermia and external
heat applied with the chills. Constant special nursing
care was provided. A few doses of sodium thiosul-
fate were given intravenously. Nembutal was given
for restlessness.

Later Course. — ^On December 18, the red count was
650,000 with a hemoglobin of 10. The urine continued
to be reddish black. Because of the fact that the pa-
tient was obviously terminal and had failed to respond
to any of the recognized forms of treatment, I de-
cided to give sulfanilamide. This had been considered
before but withheld because of the fear of further
aggravating the severe anemia. Therapy with 20 cubic
centimeters of prontosil every four hours was insti-
tuted w’th almost miraculous response. The temperature
dropped to normal and remained normal thereafter, and
all the previously described signs disappeared. In two
days the patient became rational and was able to take
sulfanilamide by mouth, this being given in doses of
15 grains four times daily for three days and then
reduced to 10 grains three times daily. There was no
more black urine, although it was discolored from the
prontosil. The red count increased rapidly without any
further transfusions. She was given ferrous sulfate
with vitamin B in the form of hematinic plastules.
The liver and spleen gradually diminished in size and
the jaundice cleared up.

She continued to be nauseated, however, and devel-
oped attacks of severe pain in the right upper abdo-
men referred to the right shoulder blade which re-
quired frequent doses of morphine for relief. On De-
cember 29, x-rays showed non-visualization of the
gall bladder after oral dye. A diagnosis of gall-bladder
disease with stones was made. She was given dehydro-
cholic acid with atropine and a high fat diet for a week,
but the attacks became worse on this regime. On Jan-
uary 19, 1938, her red count was up to 2,630,000 and
hemoglobin 47. She was taken to the operating room
and under nitrous oxide anesthesia the gall bladder was
explored through a small subcostal incision. The gall-
bladder wall was somewhat thickened ; the mucosa
had a strawberry appearance. It was filled with dark
brown bile and contained six or eight faceted soft,
brown gall stones. The stones were removed and the
gall bladder was drained. It was felt that these stones
were probably the result of the extreme concentration

of blood pigments from the hemolytic anemia rather
than the result of gall-bladder infection. Considering the
general condition of the patient, a cholecystotomy
seemed preferable to a cholecystectomy.

Her postoperative course was uneventful. She was
up in two weeks and on February 13 she was dis-
charged from the hospital. Her red count at that time
was 4,080,000 with a hemoglobin of 60. She felt fine.
She was instructed to take quinine, 10 grains daily, and
continued to take ferrous sulfate.

She has been under observation intermittently since
that time. There have been no recurrences of the
symptoms of malaria or gall-bladder disease. In Feb-
ruary, 1939, she again left for French Equatorial Africa
to continue as a missionary, and several reports reveal
that she is in good health.

Comment

The interesting features of this case are the
occurrence of blackwater fever, a tropical dis-
ease, in Northern Michigan, the unusually high
temperature 108.4 degrees axillar}% the extreme
anemia, the dramatic response to prontosil and
sulfanilamide in an obviously terminal patient,
and the removal of blood pigment stones from
the gall bladder.

Bibliography

1. Blackie, \\'. K.; Blood transfusion in the treatment of
blackwater fever. Lancet, (November) 1937.

2. Blocklock, B. : The etiology of blackwater fever. Ann.

Trop. Med., (April) 1923.

3. Blocklock, 19. B.: The mechanism of blackwater fever and

certain allied conditions. Brit. Med. Jour., (July) 1928.

4. Camody, E. P. : Blackwater fever. So. African iMed. Jour.,
(July) 1929.

5. Chesterman, C. C. : The treatment of blackwater fever by

oral sodium bicarbonate. Lancet, (June) 1929.

6. Cozgeshall, L. T. ; Malaria. Prophylactic and therapeutic
effect of sulfonamide compounds (sulfanilamide and sul-
fanilyl sulfanilate) in experimental malaria. Proc. Soc. Ex-
per. Biol, and Med., 38:768-773, (June) 1938.

7. De Valle, C. M.: A case of blackwater fever and its

urological aspect. N. Y. State Med. Jour., (November) 1930.

8. Fairley, R. U. : Cholelithiasis as a sequel of blackwater

fever. Lancet, (June) 1930.

9. Fernan, Nunez M.: Blackwater fever: a clinical review of

fifty-two cases. Annals Int. Med., (March) 1936.

10. Fernan, Nunez: Hemoglobinuric fever: Is it an allergic

phenomenon? Am. Jour. Tropical Med., (September) 1936.

11. Hasselman, C. M. : Blackwater fever in the Philippine

Islands. Jour. Philippine Islands Med. Assn., (January)
1934.

12. Hill, R. A.: Prontosil in treatment of malaria. Report of

100 cases. So. Med. Jour., (December) 1937.

13. Low, G. M,: Blood transfusions in blackwater fever.

Lancet, (September) 1928.

14. Morgatroid, F. : Modern treatment of blackwater fever.

Med. Press, 196:173-175, (IMarch 2) 1938.

15. Pakenham, R., and Rennie, A. T. : Malaria therapy. Sul-

fonamides. Lancet, 2:79, (July 9) 1938.

16. Sampson, M. C. : Blackwater fever and its relation to ma-

laria. So. African Med. Jour., (May) 1932.

17. Soromenho, L. : Spirochetes in the feces of patients with

blackwater fever. Lancet, (November 8) 1930.

18. Tolleson, H. M.: The treatment of hemoglobinuric fever.

Jour. Med. Assn. Georgia, (February) 1930.

19. Whitmore, E.R. : Further study of the blood in blackwater

fever. United Fruit Co., Eighteenth Annual Report, 1929.

Jour. M.S.M.S.

990

EXAMINATION OF SELECTEES

Examination of Selectees
as a Society Activity

The Tuscola County ^Medical Society has been
conducting group examinations of registrants
under the Selective Service Act as a Society ac-
tivity. The manner in which these examinations
are being conducted appears to be somewhat un-
usual and therefore worth while reporting.

divided into three groups of four, each group
acting as an examining unit. The secretary has
acted as a sixth examiner with each unit.

The iMedical Superintendent of the Caro State
Hospital for Epileptics offered the use of the
gy-mnasium of the institution recreation build-
ing as an examining center and the facilities of
the institution laboratory’ for urinalyses. All
blood specimens are sent to the I\Iichigan De-
partment of Health Laboratory for routine Kahn

Prior to May, 1941, the examinations for the
Local Board had been done by three Caro
physicians. With the death of one of these
physicians, the two remaining found it impos-
sible to examine enough men to fill the county’s
quota for induction into service.^ The members
of the Local Board approached the officers of the
Society and, after obtaining their approval, inter-
viewed the individual members to ascertain their
willingness to serve as examiners for the Board.
The response was unanimous. The names of the
younger members were then submitted by the
Board to Governor VanWaggoner for approval;
all names submitted were approved.

Because of his central location and proximity
to the Draft Board office, the secretary of the
Society was designated as the chief examining
officer. The dentists of the county have co-
operated splendidly, one working with each unit
in a group examination ; several have assisted
more than once. The examining physicians were

tests. Examining booths along the windowed
side of the gymnasium are formed by suspend-
ing sheets from overhead wires. Each physician
works in the same booth at all examinations. The
accompanying diagram explains the physical set-
up. Registrants wait in the lobby until called for
examination.

The secretaries of the Local Board and of the
Society arrange the dates of examinations. The
secretary of the Local Board sends the “Official
Notice to Appear for Examination” to a group of
between forty-five and fifty registrants. At the
sarnie time the secretary of the Society notifies the
members of a unit that an examination will be
held. The examining units work in rotation.
Each unit completes its work in a half day and
it has not been necessary' for any unit to appear
more often than once a month.

As each registrant enters the g}’mnasium, he
is assisted in filling out the questions on the first
page of the examination form. At this time a

December, 1941

991

EXAMINATION OF SELECTEES

psychiatric evaluation of the registrant is made.
He then passes to the first booth. Here he dis-
robes and the blood specimen is taken. Carrying
his examination blanks and clothes with him, he
is examined in each booth in turn. At the last
booth, a urinalysis is obtained and the blanks col-
lected. Three male attendants from the insti-
tution have assisted with the taking of blood
for Kahn tests, removal of impacted wax from
ears, and the collection of urine specimens. As
each examiner completes his part of the exam-
ination, he makes a penciled note in the margin,
classifying that portion of the examination as
lA, IB, or IV. He is familiar with the Selective
Service standards for his particular examination
and his notation is a valuable timesaver to the
chief examiner in completing the forms when
the results of the urinalyses and Kahn tests are
available. The completed forms are returned to
the secretary of the Local Board.

The members of the Local Board have been
very enthusiastic over this plan. It allows them
to consider large groups of registrants for final
classification at one time and makes their meet-
ings, with absence from their regular occupations,
less frequent. Thus far, none of the physicians
or dentists has objected to spending the time re-
quested; their cooperation has been very grati-
fying to the Society officers. The percentage of
rejections at the Army Induction Station has
been low. Of the last group of thirty-nine sent
to the Induction Station, there were five rejec-
tions. Three had been referred to the Medical
Advisory Board and passed by that body. One
was rejected because of “acute anterior urethritis
(gonococcic) of three days duration.” The fifth,
a registrant with rheumatic heart disease, repre-
sents the only real failure of the examining
group. Needless to say, this record of efficiency
is pleasing to all concerned.

I^SMS

PLASMA TRANSFUSION ABOARD SHIP
SAVES “KEARNY” CREW MEMBER’S LIFE

How blood plasma, donated by an unknown American
through his local Red Cross chapter to the Army and
Navy Blood Plasma Bank, was used on the torpedoed
destroyer Kearny t© save the life of a seriously injured

sailor, is told in a statement issued by the United States
Navy Department, November 4. While the destroyer
was still limping into port, a series of three transfusions
was performed with plasma flown from shore-based
supplies by a patrol plane and parachuted into the water
from where it was rescued and taken aboard the
Kearny. The statement issued by the Navy Department
follows in full :

“Blood plasma taken from the bank being raised by
donations which citizens of the United States are mak-
ing to the Navy through the American Red Cross was
credited today with saving the life of Leonard Fronta-
kowski. Chief Botswain’s Mate, USN, one of the 10
men injured when the USS Kearny was torpedoed
on the night of October 16-17.

“The plasma, delivered far at sea by a Navy patrol
plane, was used in three transfusions which a Naval
surgeon administered in a dramatic operation performed
aboard the damaged destroyer as it limped to port after
being hit by a German submarine.

“Frontakowski, whose home is at 370 Hamilton Ave.,
Norfolk, Va., was not injured in the torpedo attack
itself, but was hurt seriously when struck by a life-
boat which was torn from its moorings and swept
across the deck of the ship as the damaged destroyer
rolled in the rough North Atlantic seas.

“The ship’s ‘sick bay’ had been wrecked by the tor-
pedo’s explosion. However, Frontakowski was carried
to the ship’s after-dressing station where first aid was
administered by an unidentified Pharmacist’s Mate.

“Meanwhile, another destroyer was on its way to as-
sist the Kearny and when she arrived 18 hours after
the submarine attack. Lieutenant (junior grade) R. W.
Rommell, Medical Corps, U. S. Naval Reserve, a resi-
dent of Oneida, New York, was transferred to the
Kearny in a motor whale boat to attend the injured
men.

“Soon after Dr. Rommell’s arrival, a patrol plane,
which had put out from a shore base, reached the
scene and dropped a package of blood plasma, wrapped
in waterproof covering, on the sea beside the second
destroyer. It was recovered and taken aboard the
Kearny.

“Dr. Rommell used the blood plasma to give Fronta-
kowski three transfusions. The sailor’s condition,
which had been considered very grave, began to show
steady improvement.

“Frontakowski is recovering at a service hospital in
Iceland now and is believed to be out of danger.

“Surgeons at the Navy Department pointed out that
the plasma used in saving Frontakowski’s life far out
in the North Atlantic may have come from a donor in
any of several inland states, and emphasized the impor-
tance of everyone joining in the drive to provide the
blood plasma needed to equip ships of the fleet.

“Approximately 20,000 donations have been made to
the Red Cross, and of these 9,000 have been processed
and turned over to the Navy and 6,000 to the Army.
It is estimated that at least 100,000 units are required
for each branch of the service to meet ordinary
peacetime needs.

“Persons interested in making contributions to the
blood bank are requested to contact chapters of the
American Red Cross participating in the program.”

Active blood collecting projects are now sponsored
by Red Cross chapters in the following cities : Wash-

ington, Baltimore, Philadelphia, New York, Buffalo,
Rochester, and Indianapolis. A number of other chap-
ters are now completing plans for collection projects in
their areas, the Red Cross announces.

992

Jour. M.S.M.S.

e ^eaion J

My Sincere Wish to cdl members of the
Michigan State Medical Society for a

MOST HAPPY HOLIDAY SEASON!

May the New Year bring an abundance
of health and courage to each and every
doctor of medicine so he may perform the
daily tasks assigned to him and do his part
in solving problems which face him individ-
ually and as a member of an important
group.

President, Michigan State iMedical Society

December, 1941

99.1

^ EDITORIAL X-

MEDICAL PREPAREDNESS IN MICHIGAN

■ Michigan is faced at once with the procure-
ment of one hundred medical officers for the
armed forces of the United States. That is not
all. In the possible near future, the quota for
Michigan will be seven hundred more medical
officers. This amounts to about eighteen per
cent of the practicing physicians in the state. In
a medical society of one hundred members, eight-
een of them may be needed to fill Michigan’s
quota.

The United States is developing a medical
corps of over eleven thousand medical officers.
This compares with some twelve hundred a very
few years ago. At the present time the age limit
for physicians with no army training is thirty-five
years. Undoubtedly, many of the younger men
will apply for commissions but it is questionable
that there are eight hundred physicians in Mich-
igan under thirty-five years who are available.
It is probable the age limit will be raised.

In order to make the service attractive to the
older and more trained men, the Preparedness
Committee of the A.M.A. has been asked to rec-
ommend higher initial commissions for medical
specialists and higher pay arrangements with
more efficient use of present medical officers.
(According to an administrative medical officer
some of this inefficient use of the doctors in serv-
ice is due to their own lack of executive ability.)
An additional recommendation by the state com-
mittee is that certified specialists should be given
initial rank of Major.

A further activity of the state committee
will be to prepare and arrange the collection
of a questionnaire which will be filled out by
each County Preparedness Committee. The
data in this questionnaire will enable the
state committee to have a comprehensive
knowledge of the distribution and availability
of physicians should a national crisis become
apparent.

Other aids for encouraging commissions of
medical officers are requests to the hospital ad-
ministrators that they encourage interns, resi-

dents, and staff members under the proper age
tO' apply for commissions in the Medical Reserve
Corps and that medical students be encouraged
to seek appointments in the Medical Adminis-
trative Corps.

There is, at present, an understanding be-
tween the Selective Service, the Military
Forces and the colleges that any medical stu-
dent, once accepted in a reputable medical col-
lege, may be commissioned in the Medical Ad-
ministrative Corps and then will not be called
to active duty until after completion of his
medical education.

The deans of the medical schools also have
been asked to avoid the certifications to teaching
positions of doctors under the age of thirty, and
also to: discontinue requesting their deferment in
the draft.

A difficult problem and much labor await the
Medical Preparedness Committee but they seem
to have started the solution with a sound under-
standing of the needs and a desire for fair
treatment to doctors of medicine.

YOU HAVE THE FACTS

■ A LETTER sent to each member of the Michi-
gan State Medical Society on November 15,
1941, by the Executive Committee of The Coun-
cil presented a very informative report on Michi-
gan Medical Service.

Perhaps most important was the news that the
Board of Directors of Michigan Medical Service
has finally found a trained insurance man capable
of managing the administration of the program.
For many months contacts had been made but
fulfillment was impossible for one reason or an-
other.

Two paragraphs of this letter are especially
worthy of note:

“Surgery in the general population runs only
40 cases per 1,000 whereas surgery with Mich-
igan Medical Service groups has been running
to 139 cases per 1,000. This experience in the

994

Jour. M.S.M.S.

TAXES

first six months of newly-enrolled groups,
taxes severely the reserves of Michigan Med-
ical Service but incidentally reveals that 3^
times more operations are performed under
the M.M.S. program than are performed in the
general population.”

This surely demonstrates that the additional
amount of service created under this budgeting
plan should tend toward a more healthy popula-
tion and an increase in the amount of preventive
surgery.

The other paragraph toi be quoted needs no
comment. It is a sermon in itself.

“It must be appreciated that Michigan Med-
ical Service is a young corporation and that
perfection can only be had through a process
of evolution. Its initial development was oc-
casioned by a consumer demand for a program
protecting the low-income workers against
catastrophic illness. This demand will have
to be met; either by cooperative efforts of the
medical profession, or by political or social
agencies. Would a political or social program
by consistent with the democratic practice of
Medicine and preserve its tradition?”

MERRY CHRISTMAS

■ In extending the greetings of Christmas to
every member of the Michigan State Medical
Society, the officers and councilors review with
gratification the accomplishments of the past
year. Organized medicine in Michigan has kept
pace with scientific advancement, while at the
same time meeting and solving its ever-increas-
ing social and economic problems.

Looking to the year 1942, a period of even
greater service by the medical profession to the
citizens of Michigan is anticipated — a service: de-
veloping better health and prosperity to all,
epitomized in the sincere greeting, “A Happy
New Year.”

WRITE ON THYMUS TREATMENT

“Treatment of Successive Generations of Rats w th
Thymus Extract and Related Substances,” a summary
of two years’ research in the anatomical laboratoGes
of the Wayne University College of Medicine, is pub-
lished in the current issue of the nationally circulated
journal, Endocrinology. Prof. Warren O. Nelson and
Instructor Albert Segaloff of the College staff are the
authors.

The Wayne study was aided by grants from the
Committee on Scientific Research of the Amer.can
Medical Association and the Works Project Admin-
istration.

You Are Going to Pay
More Taxes

By Hazen J. Payette, LL.B.

This article on. Income Taxes is the first in a series
of two written especially for The .Journal of the Mich-
igan State Medical Society by Mr. Payette, a member
of the Detroit Bar, out of a wealth of experience with
the Internal Revenue Code.

N September 20, 1941, at 12:15 p.m. E.S.T.
the Revenue Act of 1941 became effective.
While this was not a complete new act but merely
amendments to the Internal Revenue Code, all
payers of income tax in prior years will be affect-
ed by it as well as hundreds of thousands of per-
sons who heretofore have escaped the payment
of income taxes.

In attempting to comment on income taxes for
1941, I am mindful of the fact that additional
tax acts will probably be passed either in 1941,
or in 1942 and made retroactive to one’s 1941
income. What these changes will be it is im-
possible toi guess and therefore this article is
based on the above mentioned Act. In addition,
certain suggestions are made which might prove
beneficial to one’s tax position if acted upon
this year.

The present Act is not the so-called “Adminis-
tration Tax Bill” although it does contain some
of its provisions. Numerous provisions were
eliminated to expedite its passage with the prom-
ise that a subsequent bill would be introduced
which would provide additional revenue. The
present Act will yield slightly in excess of $3,-
500,000,000.

This discussion of the Act is directed primarily
to the medical profession and will not touch on
the new or increased corporation, excise and ex-
cess profits tax. In passing, however, it might be
well to mention that material increases have been
made in estate and gift taxes (in some instances
the new estate taxes represent an increase of 424
per cent) and while the new rates on gift taxes
do not become effective until 1942, the estate
taxes will be collected as of the effective date
of this Act. ,

Although the amendments to the Act affecting
1941 income are not numerous in comparison,
they are vital in that they generously affect the
amount of tax one will pay. Those changes can
be summarized as follows :

December, 1941

995

TAXES

(a) Integration of 10 per cent defense tax
into basic surtax.

(b) Reduction of personal exemption for mar-
ried persons from $2,000 to $1,500.

(c) Reduction of personal exemption for sin-
gle persons from $800 to $750.

(d) Restriction in the allowance to the head
of a family on the first dependent in certain
cases.

(e) Increased surtax rates.

(f) Optional returns.

(g) Optional reporting of increment on U. S.
Savings and Defense Bonds.

(h) Lowering of minimums on Information
Tax returns.

Who Must File a Return

The Act contains these provisions ;

The following individuals shall each make under
oath a return stating specifically the items of his
gross income —

(1) Every individual who is single or who is mar-
ried but not living with husband or wife, if having a
gross income for the taxable years of $750 or over.

(2) Every individual who is married and living
with husband or wife — if (A) such individual has for
the taxable year a gross income of $1500 or over, and
the other spouse has no gross income; or (B) Such
individual and his spouse each has for the taxable
year a gross income and the aggregate gross income
is $1500 or over.

Even though a single person may have the
status oif “head of the family” with one or more
dependents, he would still have to file a return
if his income was $750 or over; a married per-
son having a gross income of over $1,500, who
is maintaining a home for his wife and minor
child or children would also have to file a return
although in each instance noi tax would have to
be paid.

A husband and wife are still permitted to file
either joint or separate returns. However, in
every such instance where there are separate
incomes a mathematical problem is presented and
a decision must be reached as to which is the
more economical. In making this decision, bear
in mind that in joint returns the contributions,
losses et cetera of one party may be used to
offset the gains of the other. On the other hand,
a joint return may bring one in the upper surtax
brackets and result in a higher tax than would
have been paid if individual returns were filed.

As an illustration of the application of the

Act let us consider the potential report of a
married physician, living with his wife, main-
taining a household, who has two dependent

children and whose items of income and deduc-
tions are as follows :

Income

Income from profession

(earned income) $6,000.(X)

Dividends 600.00

Rents and royalties 780.00

Fully taxable interest 100.00

Gross income $7,480.00

Deductions

Taxes $ 482.00

Interest paid 82.00

Losses from fire, theft, etc.

(not capital losses) 320.00

Bad debts 100.00

Contributions 110.00

Total deductions 1,094.00

Net income $6,386.00

Credits against net income for
surtax purposes :

Personal exemption $1,500.00

Credit for dependents 800.00

2,300.00

Surtax net income $4,086.00

Surtax (see surtax tables below) $311.18

*

Net income $6,386.00

Credits against net income for

normal tax purposes :

Personal exemption $1,500.(X)

Credit for dependents 800.00

Earned income credit (10%
of either earned income or
net income, whichever is

less) 600.00

2,900.00

Normal tax net income... $3,486.00

Normal tax (4% of $3,486.00) .... 139.44

Total normal and surtax $450.62

Note that the amount subject to surtax is
greater than that subject to normal tax. This
is true because the earned income credit is one
of the items not allowed as a deduction for sur-
tax purposes.

It is possible under the Act to have a situa-
tion where the taxpayer will not be required to
pay a normal tax but nevertheless must pay
a surtax. For example, where a married man

996

louR. M.S.M.S.

TAXES

with one dependent has an exemption of
$1,900.00 and has an earned income of $2,100.00,
his earned income credit added to his exemptions
would total more than his income and he would
therefore have no normal tax to pay ; but since
his earned income credit of $210.00 is not al-
lowable for surtax purposes, he would be en-
titled to only $1,900.00 in exemptions and would
therefore be required to pay a surtax on $200.00
which would amount to $12.00.

Surtax Tables

Surtax tables as set up under the Act start
at 6 per cent with the rate increasing rather
abruptly. The rates up to and including $32,-
000.00 are as follows;

the Optional Return, so a thorough explanation
here would merely waste valuable space. How-
ever, I do wish to point out that should a hus-
band and wife have separate incomes, one would
be permitted to file the regular form while the
other filed the optional form. If this were done,
each person would be considered as a single per-
son and would therefore be entitled to a personal
exemption. The credit for dependents would
then be taken by the person providing support
for same.

Capital Assets

The law as to the acquisition and disposition of
Capital Assets has not been changed. However,
there has been some confusion as to the appli-

I£ the surtax net income is: The surtax shall be:

Not

over $2,000.00.

net income

Over

2,000.00 but not

over

4,000.00

$ 120.00 plus 9

per

cent

of

excess

over

$ 2,000.00

Over

4,000.00 but not

over

6,000.00

300.00 plus 13

per

cent

of

excess

over

4,000.00

Over

6,000.00

but

not

over

8,000.00

560.00 plus 17

per

cent

of

excess

over

6,000.00

Over

8,000.00

but

not

over

10,000.00

.... 900.00 plus 21

per

cent

of

excess

over

8,000.00

Over

10,000.00

but

not

over

12,000.00

per

cent

of

excess

over

10,000.00

Over

12,000.00 but

not

over

14,000.00

.... 1,820.00 plus 29

per

cent

of

excess

over

12,000.00

Over

14,000.00

but

not

over

16,000.00

.... 2,400.00 plus 32 per

cent

of

excess

over

14,000.00

Over

16,000.00

but

not

over

18,000.00

.... 3,040.00 plus 35

per

cent

of

excess

over

16,000.00

Over

18,000.00

but

not

over

20,000.00

.... 3,740.00 plus 38

per

cent

of

excess

over

18,000.00

Over

20,000.00

but

not

over

22,000.00

.... 4,500.00 plus 41

per

cent

of

excess

over

20,000.00

Over

22,000.00

but

not

over

26,000.00

.... 5,320.00 plus 44 per

cent

of

excess

over

22,000.00

Over

26,000.00

but

not

over

32,000.00

.... 7,080.00 plus 47

per

cent

of

excess

over

26,000.00

These tables continue up to $5,000,000.00 and those persons having an income over that figure
are required to pay a surtax of $3,723,780.00 plus 77 per cent of the excess over $5,0(X),000.00.

The Optional Return

The optional return was designed to simplify
the filing of returns for the thousands of new
taxpayers this year. While it is an arbitrary
method, it is assumed that the use of this return
will result in the filing of fewer falsified returns,
as the deduction allowed, in addition to the per-
sonal exemptions and the credit for dependents,
is approximately 10 per cent.

The use of this form is restricted to those
having a gross income of $3,000.00 or less and
whose income “consists wholly of one or more
of the following: Salary, wages, compensation
for personal services, dividends, interest, rent,
annuities, or royalties.”. In the tables accom-
panying this form, a specific tax is listed for
gross incomes from $750.00 to $3,000.00 with
each bracket of $25.00 paying a different tax.

A professional man would not be permitted
to deduct any items of expense, were he to use

cation of short term losses and for that reason
the procedure is deemed worthy of comment.
The rule on short term losses is that they may
be deducted to the extent of short term gains
for the same year. If one’s short term losses ex-
ceeded his short term gains in the 1940 return,
such losses may be deducted from the short term
gains in 1941 and such deduction is only limited
by the taxpayer’s 1941 net income.

It might be well to point out that among the
numerous suggested changes, several were pro-
posed affecting Capital Assets. While no defi-
nite information is available, it is assumed by
many that there will be changes in the manner
in which profits on “long term” and “short term”
gains are taxed. With this in mind, a thorough
study of one’s securities is indicated. The tax-
payer should prepare at this time to take ad-
vantage of those deductions which might not be
available in future. Examine the advisability of

December, 1941

997

TAXES

disposing of those securities which are about to
pass from one time bracket to another. It may
be advisable to dispose of certain assets at a
profit to offset certain losses incurred during the
year. As it is possible that the new tax bill
may not permit the deduction of short term losses
incurred in the preceding year, it might be ad-
visable to dispose of certain assets at a profit
in order tO' absorb losses you have incurred dur-
ing this year. Action must be taken before the
end of the taxable year so that full advantage
may be obtained. Adversely, if one is planning
certain decorations or repairs which would come
under the heading of “Business deductions” it
might be well to wait until next year. Naturally,
the same would hold true for business expenses.

Deductions

In discussing deductions I assume that the
taxpayer is familiar with the fact that the usual
professional expenses are deductible. These are
many. To enumerate them would take several
paragraphs.

While equipment is generally considered as
a capital asset and the taxpayer is only per-
mitted to take depreciation on it, this is not
true of tho'se numerous items which must be
constantly replaced. Magazines in the waiting
room, malpractice insurance, dues in professional

societies, expense of attending professional con-
ventions, scientific journals, and the cost of
maintenance of an automobile to the extent to
which it is used in carrying on a profession are
items of business deduction. Contrasted to the
rule that business expenses are deductible, the
Treasury Department has ruled that the cost of
uniforms of surgeons and nurses as well as
their cost of laundering, is not deductible !

A good rule to follow in deciding deductions
for business expense: If the expense is incurred
because it is essential to a profession or if it
is required or expected of the physician in order
that he may receive his compensation, it is de-
ductable. However, if it is primarily connected
with one’s living, family or personal welfare,
regardless of whether it may subsequently bene-
fit one in his profession, it may not be deducted.

A doctor who uses part of his home as an
office may deduct a proportionate share of the
expense for heat, light, repairs, depreciation, in-
surance, cleaning service, et cetera. This appor-
tionment may be on the basis of use, ratio of
rooms used, or ratio of area. As no^ definite
rule has been set, the merits in each case will
govern.

717 Ford Building,

Detroit, Michigan

(Part II will appear in the Jamcary issue)

ADVANCED COURSE ENT SURGICAL ANATOMY

at the

UNIVERSITY OF MICfflGAN MEDICAL SCHOOL

Second Semester — February 12 to June 4, 1942. Thursday, 1:00 to 10:00 P. M.
each week. Professor Rollo E. McCotter.

Dissection of specific regions of the body to refresh previous knowledge and
as preparation for surgical specialties ot investigative work. If time permits and
suitable material is available, the study may be extended to the microscopical
and developmental anatomy of the region. Informal lecture the first part of the
afternoon followed by dissection of the part under consideration. Graduate or
{x>stgraduate credit can be arranged. Fee $25.

For further information, address:

Department of Postgraduate Medicine
University of Michigan
Ann Arbor, Michigan

998

Jour. M.S.M.S.

CORONER ACTION REQUIRED IN ALL CASES NOT SEEN BY
PHYSICIAN DURING THIRTY-SIX HOURS PRECEDING DEATH

Attorney General's Opinion to State Board of Embalmers and Funeral Directors

We have your recent letter in which you ask
for a construction and clarification of the mean-
ing of Section 19, Chapter XIII, of the Code of
Criminal Procedure (Act 175. P.A. 1927 ; Section
17421, C. L. 1929; Section 28.1187, Mich. Stat.
Ann.) which reads:

“It shall be the duty o£ any physician and of any
person in charge of any hospital or institution, or of
any person who shall have first knowledge of the death
of any person who shall have died suddenly, accidental-
ly, violently or as the result of any suspicious cir-
cumstances or without medical attendance up to and
including at least thirty-six hours prior to the hour of
death, or in any case of death due to what is commonly
known as an abortion, whether self-induced or other-
wise, to immediately notify the coroner of the death. It
shall be unlawful for any undertaker, embalmer or other
person to remove any body from the place where such
death occurred, or to prepare same for burial or ship-
ment, without first notifying the coroner and receiving
permission to remove the body.”

We refer you to a former opinion of this de-
partment (1933-34 O.A.G. 166) which discusses
the history and purpose of this statute in detail.
The apparent purpose of the statute is tO' assist in
the discovery of crime resulting in death and
to provide a method for determining the cause
of death in all doubtful cases. Without repeating
what was said in that opinion, we concur in the
conclusion that this statute requires the action of
a coroner in all cases of death where a physician
has not seen the deceased during the last thirty-
six hours preceding the hour of death.

We also direct your attention to Section 8 of
Act 343, P. A. 1925 (Section 6580, C. L. 1929;
Section 14.228 Mich. Stat. Ann.) which provides

in part :

“In case of any death occurring without medical at-
tendance it shall be the duty of the undertaker or
person acting as such to notify one of the county cor-
oners, or a justice of the peace acting as coroner, who
shall investigate or hold an inquest as the circumstances
require and shall certify as to the cause of such death
on the death certificate and shall sign the same offi-
cially, as coroner or acting coroner. * * ”

You comment that :

“An extremely large proportion of deaths are due
to such chronic disorders as cancer, heart ailments, et
cetera. In such cases where medical attention has been
provided and adequate diagnosis has been made, it is
seldom that the physician is in actual physical attend-
ance during the thirty-six hours immediately preceding
death. Does this law require that such cases shall
be referred to a coroner? We feel that they should
not.”

December, 1941

We cannot concur in your conclusion as it
seems possible that in some cases of this sort
some other cause of death might have intervened
within the final thirtv-six hours of the decedent’s
lifetime ; for example, one suffering from such
an ailment might be the victim of euthanasia,
might commit suicide, or might die of some cause
entirely unrelated to the previously diagnosed
ailment. The fundamental purpose of the statute
in question requires the action of a coroner in
such cases so as to ascertain definitely the cause
of death and aid in detecting crime.

You further comment :

“There is ample reason to believe that a physician
whose first call occurs within this thirty-six hour period
may not have sufficient time or information tO' make
a proper diagnosis and, therefore, should be required
to refer the case to a coroner.”

In such cases the statute permits, and indeed in
some cases requires, the attending physician to
notify the coroner.

You present this further question :

“Whether a person who died directly as the result
of an accident, but a year after such accident actually
occurred, would be considered to have died ‘accidentally’
within the meaning of the above act.”

The word “accidentally” must be read in con-
nection with the preceding language and meaning
must be given to the entire phrase “any person
who shall have died suddenly, accidentally, or
violently.” Reading it in this way, it is clear
that it does not refer to a person who^ dies as a
result of an accident after the lapse of a year
or any other extended period of time. In the im-
mediately following phrase, the statute refers to
“the result of any suspicious circumstances,” and
had the legislature intended the meaning, it no
doubt would have used the phrase “the result of
an accident.”

I

It is our opinion that the word “accidentally”
must be given its usual dictionary meaning of a
sudden and unforeseen event.

Very truly yours,

Herbert J. Rushton
A ttorney G eneral.

No. 20313 of
July 7, 1941.

999

>f YOU AND YOUR BUSINESS ^

THE STATE OF WASHINGTON SOLVES
ITS STATE-MEDICINE THREAT

According to Northwest Medicine, a limited
form of state medicine was inaugurated in the
state of Washington last autumn by the passage
of an initiative bill by a majority of 100,000 votes
favoring an old-age pension measure which be-
came effective April 1. This bill provides a pen-
sion of $40 per month for all citizens who have
attained the age of 65 ; one section of the bill pro-
vides for free choice of doctor and dentist from
legally-qualified practitioners. The setup places
the medical and dental care under a State Medi-
cal-Dental Board, including four physicians, two
dentists and one nurse, with a local board in each
of the thirty-nine counties comprising two physi-
cians, one dentist and a representative of the
County Welfare Department.

“When the actual care of patients came under
consideration,” according to N orthwest Medicine,
“there was only one available means of dispens-
ing this service. It was realized that the existing
Medical Service Bureaus, with their experience
standing over a period of years, could immediate-
ly administer the new service, and the care was
placed under these organizations, thus eliminating
lay supervision of medical service which has
been a threatened menace whenever state medi-
cine has been under consideration.”

MSMS Convention, September 22, 23, 24, 25, 1942
— Grand Rapids —

ANNUAL COUNTY SECRETARIES'
CONFERENCE

The conference of county medical society sec-
retaries will be held at the Olds Hotel, Lansing,
Sunday, January 25, 10:30 a.m. to 4:00 p.m.

As in the past, this conference will become
a joint meeting, in the afternoon, with the state
and county health officers of Michigan.

An unusually interesting program is being
developed, including a first-hand account of ci-
vilian defense in England by Chief Daniel Deasy
of the New York Fire Department, now assigned
to the Office of Civilian Defense, Washington,
D. C.

All members of the Michigan State Medical
Society will be welcomed at the County Secre-
taries’ Conference ; particularly, the presidents
and secretaries of county medical societies are
urged to attend.

MSMS Convention, September 22, 23, 24, 25, 1942
— Grand Rapids —

APPRECIATION TO MICHIGAN
LEGISLATURE AND THE GOVERNOR

The House of Delegates of the Michigan State
Medical Society unanimously adopted the follow-
ing resolution at the 76th Annual Meeting of the
State Society in Grand Rapids :

Resolvtid, That the House of Delegates of the Mich-
igan State Medical Society, in session September 16,
1941, place on its minutes an expression of appreciation
to the members and the officers of the Michigan Leg-
islature, and to His Excellency, The Governor, for the
courteous reception extended to the representatives of
the medical profession and for the thoughtful consider-
ation they have given medical and public health meas-
ures that have come before them this year.

MSMS Convention, September 22, 23, 24, 25, 1942
— Grand Rapids —

"ADVANCED HRST-AID FOR
CIVIUAN DEFENSE"

An infonnative brochure with the above title
issued by the American Red Cross is obtainable,
together with a copy of “Emergency Medical
Service for Civilian Defense,” by writing the
Office of Civilian Defense, Washington, D. C.,
attention of George Baehr, M.D., Chief Medical
Officer. No charge is made for these booklets.

MSMS Convention, September 22, 23, 24, 25, 1942
— Grand Rapids —

KEEPING OUT OF TROUBLE

Not every doctor . . . who gets tangled up
with the law deserves to be sued. One of the best
ways for a doctor to keep out of trouble is to
see to it very carefully that he does nothing which
brings him within the scope of those who' merit

Jour. M.S.M.S.

1000

YOU AND YOUR BUSINESS

damage suits against them, for if he is careful to
observe this precaution he is likely to be reward-
ed with a long and honorable career in the prac-
tice of medicine without the humiliation, em-
barrassment and (sometimes) great loss occa-
sioned by a malpractice suit.

Humphreys Springstun, of the Detroit Bar.
Doctors and Juries. P. Blakiston's Son and Co.,
Inc. 1935.

MSMS Convention, September 22, 23, 24, 25, 1942
— Grand Rapids —

EMERGENCY NEEDS FOR
NARCOTICS

The Bureau of Narcotics, Washington, D. C.,
urges physicians to keep their narcotic purchases
to a minimum. If a doctor’s average use is 100
tablets a year, the Bureau suggests that he do
not keep 500 on hand, as all reserve stocks must
be readily available for defense purposes.

While DO’ shortage O’f narcotics is tO' be feared,
excessive buying and over-stocking by practition-
ers and hospitals should be avoided, according
to the Bureau. The importance of keeping the
country’s reserve supplies of narcotics in the
hands of manufacturers and wholesale dealers,
where they are available for distribution to those
localities in which they may be most needed, is
self-evident. Drugs which have passed on to the
dispensing groups of registrants (practitioners
and hospitals) become “frozen” in that their use
has become restricted to the particular locality
and they are no longer available for distribution
toi other areas where emergency needs may arise.

MSMS Convention, September 22, 23, 24, 25, 1942
— Grand Rapids —

FEDERAL GRANT AIDS
PUBLIC-HEALTH NURSING

To aid in training graduate nurses specializing in
public-health nursing, Mrs. Dorothy Stoddard, who for
the past three years has served as a supervising nurse
in Eaton County under the W. K. Kellogg Foundation
plan, has been assigned to the staff of the department
of nursing at Wayne University for one year under
terms of a grant to Wayne from the Surgeon-General
of the United States.

Her appointment is part of a general program, aided
by the Surgeon-General’s department, to expand De-
troit’s nurse-training facilities to aid the defense pro-
gram. Sums totaling $52,190 are being administered
by Wayne under the program.

Mrs. Stoddard, a graduate of the University of
Minnesota School of Nursing and of Columbia Univer-
sity, will develop new field-work facilities for public-
health nursing students, advise students in various
problems, and coordinate field experience with the Uni-
versity program.

December, 1941

1001

Say you saw it in the Journal of the Michigan State Medical Society

■ Every month during 1941 the following advertisers carried their friendly message to
the medical profession of Michigan through the pages of The Journal:

American Can Company, New York

Holland-Rantos Co., Inc., New York

Eli Lilly & Company, Indianapolis

M & R Dietetic Laboratories, Columbus, Ohio

Parke, Davis & Company, Detroit

Petrolagar Laboratories, Inc., Chicago

S.M.A. Corporation, Chicago

The Upjohn Company, Kalamazoo

Canada Dry Gingerale, Inc., New York

Coca-Cola Company, Atlanta, Ga.

Fairchild Brothers & Foster, New York
Ferguson, Droste, Ferguson, Grand Rapids
Hack Shoe Company, Detroit
The J. F. Hartz Company, Detroit
The G. A. Ingram Company, Detroit
Mead Johnson & Company, Evansville, Ind.
Milwaukee Sanitarium, Wauwatosa, Wis.

Sawyer Sanatorium, Marion, Ohio.

Wehenkel Sanatorium, Detroit

John Wyeth & Brother, Philadelphia, Pa.

Central Laboratory, Saginaw
Cook County Graduate School of Medicine,
Chicago

DeNike Sanitarium, Detroit

The Medical Protective Company, Fort Wayne,
Ind.

Physicians Casualty Association, Omaha, Neb.
Radium & Radon Corporation, Chicago
The Rupp & Bowman Company, Toledo, Ohio
The Majiles Sanitarium, Lima, Ohio
Hotel Olds, Lansing

Physicians Service Laboratories, Detroit
The Mary E. Pogue School, Wheaton, 111.

The Zemmer Company, Pittsburgh, Pa.

Other advertisers who placed their message regularly in The Journ.a^l included:

The Baker Laboratories, Cleveland, Ohio
The Borden Company, New York
S. H. Camp & Company, Jackson
Cheplin Biological Laboratories, Syracuse, N. Y.
Corn Products Sales Company, New York
R. B. Davis Company, Hoboken, N. J.

General Electric X-Ray Corporation, Chicago

Lederle Laboratories, New York

Michigan State Apple Commission, Lansing

Picker X-Ray Corporation, New York

Philip Morris & Company, New York

Sobering Corporation, New York

Smith, Kline & French Laboratories, Philadelphia

E. R. Squibb & Sons, New York

Frederick Stearns & Company, Detroit
Winthrop Chemical Company, New York
Barry Allergy Laboratory, Detroit
Ciba Pharmaceutical Products, Inc., Summit, N. J.
National Association of Chewing Gum Mfrs.,
Staten Island, N. Y.

Radium Emanation Corporation, New York
Central Laboratories, Detroit
Hynson, Westcott & Duning, Baltimore
Physicians Heart Laboratories, Detroit
Bancroft School, Haddonfield, N. J.

Colwell Publishing Company, Champaign, 111.
National Discount & Audit Company, New York

Additional advertisers whose message appeared in The Journal during the year included:

Associated Credit Bureaus of America, St. Louis,
Mo.

A. E. Mallard, Manufacturing Chemist, Detroit
Moore-McCormack Lines, New York
Nestles’ Milk Products, Inc., Chicago, 111.

The Neuro-Psychiatric Institute of Hartford Re-
treat, Hartford, Conn.

Uhlemann Optical Company, Chicago, 111.

Alumni Association of Wayne University, College
of Medicine, Detroit
Battle Creek Sanitarium, Battle Creek
H. G. Fischer & Company, Detroit

Arthur Grabruck (Mosby Representative), Detroit
Hanovia Chemical & Manufacturing Company, De-
troit

Inter-state Postgraduate Medical Assembly of
North America, Freeport, 111.

Libby, McNeill & Libby, Chicago
Martin-Halsted Company, Detroit
Professional Pharmacy, Bay City
Professional Management, Battle Creek
Curdolac Food Company, Waukesha, Wis.

Florida Citrus Commission, Lakeland, Fla.

1002

Jour. M.S.M.S.

MICHIGAN’S DEPARTMENT OF HEALTH

HENRY A. MOYER, M.D., Commissioner, Lansing, Michigan

SMALLPOX OUTBREAK
EXPOSES INDUCTION CENTER

Smallpox traced to a Port Huron case resulted in
widespread exposures in Lapeer, St. Clair and possibly
other counties in October. One patient was a re-
jected draftee who exposed the Army induction station
in Detroit. Another was a postmaster, others were
school children and factory workers.

When the case of the rejected draftee was reported
after the State Health Department had been asked to
investigate reports of smallpox at Allentown in St.
Clair County, Selective Service sent warnings to re-
ception stations at Fort Custer and Camp Grant.
Out of 276 men in the Detroit induction station on
October 16, 203 were accepted and sixty-two were
rejected. These men came from thirteen draft boards
in St. Clair, Oakland, Washtenaw and Wayne counties.
Local health officers notified the sixty-two men of the
exposure, offering vaccination and ordering quarantine
where necessary.

Mass vaccinations were provided in some Thumb
communities as a result of the outbreak.

: — =[V|SMS

1941 BIRTHS SET NEW
RECORD

Births in Michigan will exceed 100,000 for an all-time
record this year. State Health Department figures
indicate a total of 107,000 compared with the 1927
record of 99,940.

Last year, Michigan births totaled 99,106 and infant
deaths were slightly more than 4,000. In spite of the
increase in the number of births this year, the number
of infant deaths will probably be only a little more
than the 1940 total. Willingness of more mothers to
visit their doctors early in pregnancy is lowering the
number of infant deaths. In 1930, when the
number of births was about the same as the 1940
total, the number of infant deaths was greater by more
than 2,000.

=f\/|SMS

KELLOGG GRANT AIDS
VIRUS RESEARCH

Virus research carried on in the Michigan Department
of Health laboratories will be aided by new mechanical
and electrical apparatus which will separate pure viris.
The equipment will be purchased on a $7,000 grant
from the W. K. Kellogg Foundation and will include
an air-driven ultracentrifuge and an electrophoresis
apparatus.

Under the terms of the Kellogg grant, investigations
of diarrhea of newborn infants will be one of the
first studies carried on when the specially-built equip-
ment is ready for use.

= [V|SMS

NEW WATER SUPPLY PROMPTS
DENTAL SURVEY IN ESCANABA

Escanaba’s change of water supply from a bay of
Lake Michigan to new deep wells may mean a future
reduction in dental decay among the city’s children.
The well water contains five-tenths of one part of

December, 1941

fluorides per million parts of water. For this reason,
a long-time survey is being undertaken to show the
prevalence of tooth decay in children who have known
only the old water supply, which is free of fluorides,
and by comparison the prevalence of decay in children
who use only the new well water. The survey is be-
ing made by dentists from the United States Public
Health Service, the University of Michigan School of
Dentistry and the Michigan Department of Health.

The survey will be similar to one recently made in
eight suburbs of Chicago where it was found that
children living in five communities where the water
supply contained very small amounts of fluorides had
only a half or third as many cavities in their teeth as
children in the communities taking their water from
Lake Michigan which is free from fluorine. Nearly
3,000 children from 12 to 14 years old were examined.

The Escanaba study is regarded as an ideal experi-
ment. In the same town and in the same families, it
will allow a comparison of dental health in children
who have never had fluorine in their drinking water,
and in children who have never known any other
drinking water but the new supply with flourine in it.

Studies have shown that the effect of the fluorides
(or something associated with them) occurs only
when the teeth are being formed — from birth to eight
years for all teeth except wisdom teeth and up to 14
years of age for the wisdom teeth. Adults starting
to use the water are not affected, but when once built up
in children, the protection in the teeth seems to be
lasting.

|V[SMS

WHOOPING COUGH
HIGHEST IN FIVE YEARS

Whooping cough is more prevalent in Michigan now
than it has been in the last five years and parents are
being urged to have their family physician give vac-
cine protection to babies and small children.

Forgotten Charges...??

Do your bank deposits reflect ALL the work
you do on EACH and EVERY case ... or
are there unseen leaks along the line? You
can eliminate the hazards of hit-and-miss
records when you use the DAILY LOG. It’s
REAL protection against forgot-
ten charges . . . simplified, con-
cise, complete — all in one neat
volume.

WRITE— for illustrated booklet “The
Adventures of Dr. Young in the
Field of Bookkeeping.”

COLWELL PUBLISHING CO.

1 126 University Ave., Champaign, III.

]MIESf]L(D)(G

1003

-K COUNTY AND PERSONAL ACTIVITIES -k

100 Per Cent Club for 1942 — Muskegon County
has certified 1942 dues for all of its 81 members. Con-
gratulations to Muskegon County.

* *

The Michigan Society for Crippled Children, Inc.,

held its 20th Annual Convention in Saginaw on No-
vember 6 to 8, 1941. L. Fernald Foster, M.D., Bay
City, Secretary of the Michigan State Medical Society,
was on the program discussing “Camps for Crippled
Children.”

* ♦ !(:

The Dr. Max Ballin Memorial Lectures (Ninth)
were held on Wednesday, November 26, 1941, at the
Detroit Institute of Arts. “Disturbances of Physiologic
Function in Pancreatitis and Their Recognition” was
presented by Mandred W. Comfort, AI.D., Rochester,
Minnesota ; and “Surgical Aspects of Acute Pancreati-
tis” by Robert Elman, M.D, St Louis, Missouri.

* ^ ♦

Michigan representatives to the American Medi-
cal Association Secretaries’ Conference of November
14-15 were Henry R. Carstens, M.D., President; A. S.
Brunk, M.D., Chairman of The Council ; L. Femald
Foster, M.D., Secretary; Roy Herbert Holmes, M.D.,
Editor ; Wm. J. Burns, Executive Secretary ; and J. L.
Leet, Assistant Executive Secretary.

* * *

“Heroes in Medicine,” a dramatized radio program,
is being recorded under the auspices of the Radio
Committee of the Michigan State Medical Society and

will be distributed soon to all out-state radio stations
cooperating with the Committee this year in present-
ing medical broadcasts. This interesting and pro-
gressive change in the radio program sponsored by the
MSAIS Radio Committee should insure a large listen-
ing audience throughout the state.

* * *

Liberalization of Civil Service Examinations for
nurses has been announced by the United States Civil
Service Commission. Persons over the age limit and
those who cannot meet the physical requirements may
apply for the examination if they meet all other re-
quirements of the announcement. Persons applying un-
der these provisions, if found otherwise eligible, may
be appointed for temporary duty ONLY, for the
duration of the emergency in the absence of qualified
eligibles.

t * *

Urology Award — The American Urological Asso-
ciation offers an annual award “not to exceed $500.00”
for an essay (or essays) on the result of some specific
clinical or laboratory research in urolog>'. The amount
of the prize is based on the merits of the work pre-
sented, and if the committee on Scientific Research
deem none of the offerings worthy, no award will be
made. Competitors shall be limited to residents in
urology in recognized hospitals and to urologists who
have been in such specific practice for not more than
five years. Essays shall be in the hands of the Sec-
retary, Clyde L. Deming, M.D., 789 Howard Avenue,
New Haven, Connecticut, on or before April 1, 1942.

(DUE TO NEISSERIA GONORRHEAS)

ciTi

ilver Picrate,
Wyeth, has a convincing record of
effectiveness as a local treatment for
acute anterior urethritis caused by
Neisseria gonorrheae.^ An aqueous
solution (0.5 percent) of silver pic-
rate or water-soluble jelly (0.5 per-
cent) are employed in the treatment.

A complete technique of treatment and literaturewill besentupon request

♦Silver Picrate is a definite crystalline compound of silver and picric acid.
It is available in the form of crystals and soluble trituration for the prepara-
tion of solutions, suppositories, water-soluble jelly, and powder for vaginal
insufflation.

1. Knight, F., and Shelanski,
H. A., "Treatment of Acute Ante-
rior Urethritis with Silver Picrate,”
Am. J. Syph., Gon. & Ven. Dis.,
23, 201 (March), 1939.

JOHN WYETH & BROTHER, INCORPORATEO, PHILADELPHIA

KXM Jour. M.S.M.S.

Say you saw it in the Journal of the Michigan State Medical Society

COUNTY AND PERSONAL ACTIVITIES

A. C. Furstenberg, M.D., Ann Arbor, is author of
“The Parotid Gland” which appeared in The Journal of
the American Medical Association issue of November
8, 1941.

“The Surgical Treatment of Hypertension: II. Com-
parison of Mortality Following Operation with That of
the Wagener-Keith Medically Treated Control Series”
is the title of an article appearing in the JAMA issue
of November 1, 1941, by Ward Wilson Woods, M.D.,
and Max Minor Peet, M.D., Ann Arbor.

^ ^ ^

Your Friends

Cameron Surgical Specialty Company, Chicago, Illinois
S. H. Camp and Company, Jackson, Michigan
Ciba Pharmaceutical Products, Summit, New Jersey
Coca-Cola Company, Atlanta, Georgia
Cottrell-Clarke, Inc., Detroit, Michigan

The Cream of Wheat Corporation, Minneapolis, Minnesota

Cutter Laboratories, Chicago, Illinois

Davis & Geek, Inc., Brooklyn, New York

R. B. Davis Sales Company, Hoboken, New Jersey

DePuy Manufacturing Company, Warsaw, Indiana

The above ten firms were exhibitors at the 1941 Con-
vention of the Michigan State Medical Society and
helped make possible for your enjoyment one of the
outstanding state medical meetings in the country. Re-
member your friends when you have need of equip-
ment, medical supplies, appliances or service.

* *

Mr, Charles H. Swift, chairman of the board of
Swift & Co., recently announced the establishment of a
series of fellowships for research in nutrition. The
fellowships provide for special research to be under-
taken in laboratories of universities and medical schools
with funds which the company has set aside as grants
in aid, beginning November 1, 1941. The fellowships
will be for one year but may be renewed where the
project warrants it. Any fundamental study of the
nutritive properties of food or the application of such
information to improvement of the American diet and
health will be eligible for consideration for a grant,
according to Dr. R. C. Newton, vice-president in charge
of the company’s research laboratories, who will co-
ordinate the program.

* ♦

The Michigan Pathological Society held its Octo-
ber meeting in Detroit on October 18, 1941, at Wayne
University College of Medicine and at Receiving Hos-
pital. The program consisted of a seminar on “Pri-
mary Tumors of the Brain” conducted by Gabriel Stein-
er, M.D., Professor of Neurology and Neuropathology
at Wayne University College of Medicine. Eighteen
typical cases of brain tumor with histories, operative
and autopsy findings were presented by Doctor Steiner.
Forty-seven physicians were in attendance.

The Annual Meeting of the Society will be held in
December at the University Hospital, Ann Arbor, where
the Society will be the guests of C. V. Weller, M.D.,
and his staff in the Pathological Department. The pro-
gram will consist of the showing of a motion picture
recently taken by W. M. German, M.D., on his trip
through South America, which is entitled “Columbia
South of Panama.” “Problem Cases” will also be dis-
cussed. by members of the Society.

* Jjs *

CONVENTION ECHOES

2,117 persons were registered at the 76th Annual Meet-
ing of the Michigan State Medical Society (not in-
cluding the members of the Woman’s Auxiliary).

Physician-members 1,216

Guests (mostly M.D.’s from other states) 463

Interns and Residents 154

Exhibitors 284

Grand Total 2,117

The 1,216 members of the MSMS who registered
at the Grand Rapids Convention represented the fol-
lowing specialties, according to a breakdown of the

December, 1941

Main Entrance

SAWYER SAMTDRIUM
White Oaks Farm
Marian, Ohio

For the treatment of
Nervous and Mental Diseases
and Associated Conditions

Licensed for

The Treatment of Mental Diseases
by the Department of Public Welfare
Division of Mental Diseases
of the State of Ohio

Accredited by

The American College of Surgeons
Member of

The American Hospital Association
and

The Ohio Hospital Association

Housebook giving details, pictures,
and rates will be sent upon request.
Telephone 2140. Address,

SAWYER SAMTDRIUM

White Daks Farm

Marion, Ohio

1005

Say you saw it in the Journal of the Michigan State Medical Society

CORRESPONDENCE

86c out of each $1.00 gross income
used for members benefit

PHYSICIANS CASUALTY ASSOCIATION
PHYSICIANS HEALTH ASSOCIATION

Hospital, Accident, Sickness

INSURANCE

For ethical practitioners exclusively
(56,000 Policies in Force)

LIBERAL HOSPITAL EXPENSE
COVERAGE

$5,000.00 ACCIDENTAL DEATH

$25.00 weekly indemnity, accident and sickness

$10,000.00 ACCIDENTAL DEATH

$50.00 weekly indemnity, accident and sickness

$15,000.00 ACCIDENTAL DEATH

$75.00 weekly indemnity, accident and sickness

For
$10.00
per yei

For
$32.00
per yt

For
$64.00
per yc

For
$96.00
per ye

39 years under the same management

$2,000,000.00 INVESTED ASSETS
$10,000,000.00 PAID FOR CLAIMS

$200,000 deposited with State of Nebraska for pro-
tection of our members.

Disability need not be incurred in line of duty — benefits
from the beginning day of disability.

Send for applications, Doctor, to

400 First National Bank Building Omaha, Nebraska

LABORATORY APPARATUS

Coors Porcelain
Pyrex Glassware
R. & B. Calibrated Ware
Chemical Thermometers
Hydrometers
Sphygmomanometers

J. J. Baker & Co., C. P. Chemicals
Stains and Reagents
Standard Solutions

• BIOLOGICALS-

Serums Vaccines

Antitoxins Media

Bacterins Pollens

We are completely equipped and solicit
your inquiry for these lines as well as for
Pharmaceuticals, Chemicals and Supplies,
Surgical Instruments and Dressings.

74e RUPP & BOWMAN CO.

319 SUPERIOR ST., TOLEDO, OHIO

registration cards : General Medicine ; 413 ; Surgery :

204 ; Obstetrics and Gynecology : 79 ; Pediatrics ; 42 ;
Eye, Ear, Nose and Throat: 89; Dermatology: 16;
Radiology, Anesthesia and Pathology: 44; and unclas-
sified : 329.

Over 200 office secretaries of members of the Michi-
gan State Medical Society attended the Symposium on
the Business side of Medicine, held in Grand Rapids
September 16.

Miss Winona Kullgren of Muskegon, Secretary to
Leland E. Holly, M.D., was the lucky winner of the
attendance prize.

Governor M. D. Van Wagoner was honor guest at
the Smoker of the Michigan State Medical Society
held in the Pantlind Hotel Ballroom, September 18.

CORRESPONDENCE

Michigan State Medical Society
Lansing, Michigan
Dear Secretary Foster :

A letter from Douglas, Barbour, Desenberg and
Purdy under date of August 21, 1941, apprising me of
my being released from law suit, has relieved me of
much anxiety of the possible outcome and I appreciate
greatly the protection afforded me by our Society.

I am more than ever convinced of the great advantages
derived from professional association in organized
effort of all groups to be of benefit to their members.

Sincerely,

R. Milton Rich.\rds, M.D.

Detroit.

Oct. 16, 1941.

To the Michigan State Medical Society.

Gentlemen :

At the request of the Board of Directors of the Kent
County Medical Society, I am writing to commend the
State Society and .its committees which made the re-
cent State Medical Convention such a decided success.

We physicians of Grand Rapids appreciate having the
Convention in our city, and many of us hope the Coun-
cil of the Michigan State Aledical Society decides to
return to Grand Rapids and that the Kent County
Medical Society may play a greater part in helping
your committee on arrangements and entertainment.

Sincerely,

Frank Doran, M.D., Secretary
Oct. 17, 1941 Grand Rapids.

Secretary, MSMS
Lansing, Mich.

Dear Doctor:

I wish and am indeed very happy to express my
appreciation to the MSMS for the very real ser\'-
ice it has given me. It is very gratifying, to know
that someone is “batting” for you when one is forced
to the side lines.

I am sure that if the few doctors who are not mem-
bers of the MSMS knew what they were missing, all
the king’s horses could not keep them out of the MS
MS.

Thank you very much for all you have done for me.

S. M. Lewis, M.D.
Oct. 21, 1941. Ferndale.

Jour. iM.S.M.S.

1006

Say you saw it in the Journal of the Michigan State Medical Society

IN MEMORIAM

IN MEMORIAM

L. F. Laverty of Bay City was born in Bay City,
Michigan, in 1895 and was graduated from Harvard
Medical School in 1927. Breaking into his medical
education, he left school during the World War to
be a pilot in the naval air corps. Following the war
he finished at Harvard and later interned at the
Santiago County Hospital, California. He returned
to Bay City last spring from San Clemente, Cali-
fornia, where he had been practicing. Doctor Lav-
erty met his tragic death in an automobile accident
on October 30, 1941.

Frederick W, Munro of Detroit was born in
Toronto, Ontario, June 11, 1899, and was graduated
from the University of Toronto in 1924. During 1924
and 1925 Dr. Munro interned at the Hospital for Sick
Children in Toronto. Following residency, he spent one
year at Long Island Hospital, Boston, and one year as
resident in pediatrics at the hospital for sick children,
Detroit. Since 1928 he practiced in Grosse Pointe and
latterly in his own office building at 16840 Kercheval
Avenue. He was a Diplomate of the American Board
of Pediatrics, as well as being affiliated with many
medical and civic organizations. Dr. Munro died Sep-
[ tember 15, 1941.

Arthur E. Owen of Lansing was born in Grand
! Blanc on October 6, 1883, and was graduated from the
I Wayne University Medical School in Detroit in 1907.

: Dr. Owen studied in London, Vienna and Berlin. In
' 1925 he went abroad for a second time and took post-
! graduate work at Paris and London. Dr. Owen was
I a captain in the medical corps during the World War,

I and was a major in the medical reserve corps. He was
a member of the Michigan Commandery, Military Or-
der of Foreign Wars. In Lansing, he was prominent
in civic and. iraternal affairs and was a fellow of the
American College of Surgeons and a member of the
Southern Michigan Triological Society. He died Octo-
ber 8, 1941.

RESOLUTION TO ENCOURAGE MEDICAL
COMMISSIONS

The following resolution, adopted by the MSMS
Medical Preparedness Committee, was approved by the
Executive Committee of The Council of the Michigan
State Medical Society on November 13, 1941 :

Whereas, A shortage of medical officers in the United
States Army and other Services exists at the present
time ; and

Whereas, Younger doctors of medicine seem reluc-
tant to apply for commissions in the United States
Army and other Services ; and

Whereas, The above conditions are due to certain
inadequacies and inefficiencies which do not make the
Service attractive ; now therefore be it

Resolved, That, in order to encourage requests for
medical commissions, in the United States Army and
other Services, prompt consideration be given to the
following important matters :

1. That certified medical specialists be given initial
commissions, not lower than the rank of Major;

2. That more rapid advancement in rank be provided
for medical officers ;

3. That special ratings with higher pay schedules be
provided for medical officers ;

4. That doctors of medicine be restricted to medical
work, eliminating nonprofessional duties ;

5. That more efficient use be made of the services of
present medical officers ; i.e., limiting them to profes-
sional duties and keeping them sufficiently occupied
therewith.

to the Medical Profession

WHEN nothing less than a high degree of
accuracy in a clinical test or a chemical
analysis will serve your purpose, you can
send us your specimens with confidence.
Pleasant, well-equipped examining rooms
await your patients. In either the anal3rtical
or the clinical department of our labora-
tory, your tests will be handled with the
thoroughness and exactitude which is our
undeviating routine. . . Fees are moderate.

Urine Analysis
Blood Chemistry
Hematology
Special Tests
Basal Metabolism
Serology

Parasitology

Mycology

Phenol Coefficients

Bacteriology

Poisons

Court Testimony

Directors: Joseph A. Wolf and Dorothy E. Wolf

Send f^ot 7gg Jll5t

CENTRAL LABORATORIES

Clinical. andoChBmical Research
312 David Whitney Bidg. * Detroit, Michigan
Telephones: Cherry 1030 (Resq Davison 1220

Cook County

Graduate School of Medicine

(In Affiliation with Cook County Hospital)

Incorporated not for profit
ANNOUNCES CONTINUOUS COURSES

SURGERY — Two Weeks’ Intensive Course in Surgical
Technique with practice on living tissue, starting every
two weeks. General Courses One, Two, Three and
Six Months; Clinical Courses; Special Courses.
Rectal Surgery every week.

MEDICINE — Two Weeks’ Intensive Course in Internal
Medicine, and Two Weeks’ Course in Gastro-Enterology
will be offered twice during the year 1942, dates_ to
be announced. One Month Course in Electrocardiog-
raphy and Heart Disease every month, except De-
cember.

FRACTURES & TRAUMATIC SURGERY— Two

Weeks’ Intensive Course will be offered four times
during the year 1942, dates to be announced. In-
formal Course available every week.

GYNECOLOGY — ^Two Weeks’ Intensive Course will be
offered four times during the year 1942, dates to be
announced. Clinical and Diagnostic Courses every

OBSTETRICS — Two Weeks’ Intensive Course vnll be
offered twice during the year 1942, dates to be an-
nounced. Informal Course every week.

OTOLARYNGOLOGY — ^Two Weeks’ Intensive Course
will be offered twice during the year 1942, dates to
be announced. Clinical and Special Courses starting
every week.

OPHTHALMOLOGY — Two Weeks’ Intensive Course
will be offered twice during the year 1942, dates to
be announced. Informal Course every week.

ROENTGENOLOGY — Courses in X-ray Interpretation,
Fluoroscopy, Deep X-ray Therapy every week.

General, Intensive and Special Courses in All Branches

of Medicine, Surgery and the Specialties.

TEACHING FACULTY — ATTENDING
STAFF OF COOK COUNTY HOSPITAL

Address: Registrar, 427 S. Honore St., Chicago, 111.

December, 1941

Say you saav it in the Journal of the Michigan State Medical Society

1007

READING NOTICES

I Physicians Heart!

Laboratory

I 523 Professional Building j

I 10 Peterboro Street j

Detroit, Michigan j

I Laboratory Telephones; TEmple 1-5580 i

Columbia 5580 :

: A laboratory providing the following I

: services exclusively to physicians for their i
j patients: j

I ELECTROCARDIOGRAM j

j BASAL METABOLISM j

I X-RAY of HEART j

I KYMOGRAPH X-RAY of HEART j

I VITAL CAPACITY j

j DIRECT VENOUS PRESSURE I

I Laboratory Hours: 9 A.M. to 5 P.M. j

: Interpretative opinions and records avail- \

: able only to referring plvysicians. \

PiiortssiOHAiPiiorrcTioN

A DOCTOR SAYS:

“Believe me when I say this was a
nice Christmas present and lifted quite
a worry off my mind. It was certainly
a hard, long case to fight. The whole
profession here feels that it was a
victory for all."’

READING NOTICES

SCIENTISTS MEET ON APPLE RESEARCH

The first major conference ever held on apple-use
research met in Washington on October 20, 1941. Dr.
M. L. Wilson, chairman of the special committee on
apples in the U. S. Department of Agriculture, presided.
The purpose of the conference was to review the
work done to date on apples and to map out a large
scale program of future study and investigation. Dr.
Ira A. Manville, director of the Nutrition Research
Laboratory, University of Oregon Medical School, pre-
sented the apple research work he had conducted dur-
ing the past five years.

Dr. Lydia Roberts of the University of Chicago, said
“We feel that apples are one of the most valuable
foods even though we may not be able to explain just
why. Everything is to be gained from research and
I urge that it be done.”

Among the leading authorities in the field of nutri-
tion and food research present, the Department of
Agriculture w^as represented by Dr. Louise Stanley and
members of the Bureau of Home Economics research
staff; Dr. J. T. Jardine in charge of experiment sta-
tions; Dr. E. C. Auchter, chief of the Bureau of Plant
Industry. Others who attended included Dr. L. A.
Maynard of Cornell University, chairman of the Fruits
Committee of the National Research Council, Dr. A. R.
Olpin, director of the Research Foundation and Dr.
J. H. Gourley, chief of Horticulture, Ohio State Uni-
versity.

WHY MEAD. JOHNSON & COMPANY CO-OPERATES
WITH THE COUNCIL

Voluntarily Mead Johnson & Company markets only
Council-accepted products because they have faith in
the principles for which the Council on Pharmacy and
Chemistry (and the Council on Foods) stands.

They have witnessed the three decades during whicli*
the Council has brought order out of chaos in the
pharmaceutical field. For over thirty years it has stood
— alone and unafraid — between the medical profession
and unprincipled markers of proprietary preparations.

The Council verifies the composition and analysis of
products, and substantiates the claims of manufacturers.
By standardizing nomenclature and disapproving thera-
peutically suggestive trade names, it discourages shot-
gun therapy and self-medication. It is the only body
representing the medical profession that checks inac-
curate and unw'arranted claims on circulars and adver- j
tising as well as on packages and labels.

"PETROLAGAR" NOW "PETROGALAR"

A change in the spelling of the name “Petrolagar” to
“Petrogalar” has been announced by the Petrolagar
Laboratories. The change is being made in both the
product name and corporate name.

Company officials, while pointing out that the adoption
of the new spelling does not affect the formula or
quality of the product in any way, said that they con-
sidered the change advisable to avoid any possible mis-
conception as to the nature of the product.

“Because it has never been the intention of the com-
pany to imply that agar-agar was used for any other
purpose than as an emulsifying agent, the last syllable
of the former name has been altered in favor of the
new spelling,” officials said.

Officials emphasized that no change has been made in

Jour. M.S.M.S.

1008

Say you saw it in the Journal of the Michigan State Medical Society

READING NOTICES

the size of the package, price, or formulae and that each
of the five different types of the product will carry the
new spelling “Petrogalar.” The new corporate name is :
Petrogalar Laboratories, Inc., and the address remains,
8134 McCormick Boulevard, Chicago, Illinois.

SCHERING TO MARKET SULFADIAZINE

Sulfadiazine which, according to Perrin Long, M.D.,
of Johns Hopkins University, is likely “to run sulfanila-
mide off the drug store shelves” as the drug of choice
in the treatment of hemolytic streptococcus infections
as well as in pneumonia, will be marketed by the
Sobering Corporation of Bloomfield, N. J. Sobering
has just introduced Sulamyd, sulfacetimide-Schering,
for use in urinary tract infections.

Sulfadiazine (2-sulfanilamidopyrimidine) has been
found less toxic than other anti-pneumococcic sulfona-
mides. Nausea and vomiting have occurred in only
about 10 per cent of the many cases treated with the
new drug. Higher blood concentrations are more easily
attained and maintained after oral dosage and sulfa-
diazine readily penetrates cerebrospinal, ascitic and
pleural fluids.

SOLUTION ADDED TO SQUIBB GROUP
OF AMINOPHYLLINE PRODUCTS

To provide for all forms of administration of amino-
phylline, E. R. Squibb & Sons, New York, have added
Solution Aminophylline Squibb to their previously in-
troduced line of tablets and powder. Tbe solution is
supplied in 2 c.c. ampuls containing per c.c. grains
(0.25 gram) of aminophylline in sterile aqueous solu-
tion for intramuscular injection; and 10 c.c. ampuls
containing 54 grain (0.025 gram) per c.c. of aminophyl-
line in sterile aqueous solution for intravenous injec-
tion.

Aminophylline (theophylline with ethylene diamine
U.S.P. XI) is rapidly absorbed, producing prompt
physiologic response. Recognized indications for tbe
use of aminophylline are : as a diuretic and myocardial
stimulant ; in bronchial asthma ; Cheyne-Stokes respira-
tion; paroxysmal cardiac dyspnea; and for the relief
of pain due to coronary sclerosis.

SQmBB STILBESTROL RELEASED

After two years of clinical trial, during which time
over a hundred papers were published reporting studies
in which it was used, stilbestrol, manufactured by E. R.
Squibb & Sons, New York, is now available for general
distribution throughout the country. Stilbestrol is a
synthetic estrogen possessing the physiologic properties
of estrogenic substances derived from natural sources.
Chemically, it is alpha, alpho'-diethyl-4, 4'-stilbenediol.
It is also called diethylstilbestrol.

Stilbestrol orally has a ration of effectiveness to intra-
muscular injection much superior to that possessed by
natural estrogens. It has another advantage over the
natural estrogens in that it is considerably more
economical.

Squibb Stilbestrol is supplied in three forms: (1)
Compressed tablets, either uncoated or enteric coated,
for oral administration; (2) stilbestrol in oil, for
intramuscular injection; and (3) pessaries, for vaginal
medication.

In common with other highly potent chemotherapeutic
agents, stilbestrol should be used only by or under
supervision of a physician. Literature describing its
dosage, indications and precautions is available to phy-
sicians upon request.

December, 1941

Say you saw it in the Journal of

worth while laboratory exam-
inations; including —

Tissue Diagnosis

The Wassermann and Kahn Tests

Blood Chemistry

Bacteriology and Clinical Pathology

Basal Metabolism

Aschheim-Zondek Pregnancy Test

Intravenous Therapy with rest rooms for
Patients,

Electrocardiograms

Central Laboratory

Oliver W. Lohr, M.D., Director

537 Millard St.

Saginaw

Phone, Dial 2-3893

The pathologist in direction is recognized
by the Council on Medical Education
and Hospitals of the A. M. A.

1009

the Michigan State Medical Society

THE DOCTOR’S LIBRARY

THE DOCTOR’S LIBRARY

Acknowledgment of all books received will he made in this
column and this will be deemed by us as a full compensation
of those sending them. A selection will be made for review,
as expedient.

NUTRITION IN HEALTH AND DISEASE. By Lenna F.,
Cooper, B.S., M.A., M.H.E., Chief, Department of Nutrition,
Montefiore Hospital, Ne-w York City; Formerly Food Direc-
tor, University of Michigan; Dean of School of Home Eco-
nomics, Battle Creek College; Supervising Dietitian, U. S.
Army, 1918-1919; President, American Dietetic Association,
1937-1938; and, Edith M. Barber, B.S., M.S., Writer and Con-
sultant, Food and Nutrition; Editor, Food Column, New York
Sun; and Food Column, Bell Syndicate; Lecturer on History
of Cookery, Teachers College, Columbia University; and, Helen
S. Mitchell, B.A., Ph.D., Director of Nutrition on the Staff
of the coordinator of Health, Welfare and Related Defense
Activities, Federal Security Agency, and Research Professor of
Nutrition, on Leave from Home Economics Division, Massa-
chusetts State College. Eighth edition, completely revised and
reset. 100 illustrations and 2 colored plates. Philadelphia: J.

B. Lippincott Company, 1941. Price: $3.50.

The eighth edition of this volume originally published
in 1928 has been arranged to conform closely to “A
Curriculum Diet for Schools of Nursing” published by
the National League of Nursing Education. It is very
complete and rather simply written.

MSMS

THE PREMATURE INFANT. Its Medical and Nursing Care.
By Julius H. Hess, M.D., Professor and Head of the Depart-
ment of Pediatrics, University of Illinois College of Medicine;
Attending Pediatrician, Illinois Research and Educational Hos-
pital, Cook County and Michael Reese Hospitals; and Evelyn

C. Lundeen, R.N., Supervisor, Premature Infant Station, Sarah

Morris Hospital, Chicago. 74 illustrations. Philadelphia: J.

B. Lippincott Company, 1941. Price: $3.50.

In greater than usual detail the handling of the pre-
mature infant is here discussed. The illustrations are
well selected and the application of the material is prac-
tical. Considerable emphasis is placed upon the care of
the premature infant in the home. The topography is
excellent and the contents encyclopedic. It is suitable
both for the physician and the advanced nurse.

MSMS

PRINCIPALS OF MICROBIOLOGY. By Francis E. Colien,
B.S., M.S., Ph.D., F.A.P.H.A., Associate Professor of Bac-
teriology and Preventive Medicine in The Creighton University
School of Medicine; Lecturer in Public Health and Preven-
tive Medicine, Creighton Memorial, St. Joseph’s Hospital School
of Nursing, Omaha; Director of Laboratories, Health Depart-
ment, City of Omaha; Major, Sanitary Division, United States
Army Medical Reserve; Formerly Professor of Bacteriology
and Preventive Medicine in the Central School of Nursing,
Milwaukee; and, Ethel J. Odegard, R.N., A.B., M.A., In-
structor in Sciences Applied to Nursing, College of Saint
Teresa, Winona, Minnesota; Formerly Director of Nursing
Education in the Central School of Nursing, Milwaukee; Edu-
cation Director, Miami Valley Hospital School of Nursing,
Dayton, Ohio. St. Louis: The C. V. Mosby Company, 1941.
Price: $3.00.

This is a teaching book for nurses which is arranged
for the most part to meet the recommendations of
the Curriculum Committee on Education of the Na-
tional League of Nursing Education. It is very com-
plete for this purpose and has many demonstrative cuts.
The paper is green tinted. It is recommended for
teaching purposes.

MSMS

THE FOOT AND ANKLE. Their Injuries, Diseases, Deformi-
ties and Disabilities. With Special Application to Military
Practice. By Philip Lewin, M.D., F.A.C.S., Associate Pro-
fessor of Bone and Joint Surgery, Northwestern University
Medical School; Professor of Orthopaedic Surgery, Post-grad-
uate Medical School of Cook County Hospital; Attending
Orthopaedic Surgeon, Michael Reese Hospital, Chicago; Con-
sulting Orthopaedic Surgeon, Municipal Contagious Disease
Hospital, Chicago ; Formerly Major Medical Reserve Corps,
United States Army. With 304 illustrations. Line drawings
by Harold Laufman, M.D. Second edition. Philadelphia:
Lea & Febiger, 1941. Price: $9.00.

Because of the changing national and mternational

situations notable changes have been made in the second
edition of the volume first published in 1940. These
events made it imperative for the author to emphasize
the military aspects of injuries, diseases, and disabili-
ties of the foot and ankle. However, the foot and
ankle diseases found in everyday practice have not
been neglected. The typography is excellent and the
illustrations well chosen. It is recommended for study
and reference.

MSMS

A MANUAL OF BANDAGING, STRAPPING, AND SPLINT-
ING. By Augustus Thorndike, Jr., M.D., F.A.C.S., Associate
in Surgery, Harvard Medical School; Surgeon to the Depart-
ment of Hygiene; Harvard University. Illustrated with 117
engravings. Philadelphia: Lea & Febiger, 1941. Price: $1.50.

In a pocket manual the author presents in picture
form the common types of bandages, straps and splints
taught by the Harvard Medical School. Its pictorial
system is advantageous for quick reference. In the
foreword Elliott C. Cutler says, “To the young sur-
geon ... let him remember that a neat dressing often
bespeaks a good job beneath.”

MSMS

THE 1941 YEAR BOOK OF PUBLIC HEALTH. Edited by
J. C. Geiger, M.D.. Dr.P.H., Director of Public Health.
City and County of San Francisco; Clinical Professor of
Epidemiology, University of California; Clinical Professor of
Preventive Medicine and Public Health, Stanford University
School of Medicine; Lecturer in Preventive Medicine and
Public Health, University of Southern California Medical
School. Chicago: The Year Book Publishers, Inc., 1941.

Price: $3.00.

This follows the usual make-up of the other thirteen
year books bringing in abstract form last year’s printed
reports on this subject — both the clinical material and
laboratory work. A section on “Military Hygiene”

holds prominence. The typography is good and the
material is well arranged.

MSMS

SULFANILAMIDE AND RELATED COMPOUNDS IN GEN-
ERAL PRACTICE. By Wesley W. Spink, M.D., Associate
Professor of Medicine, University of Minnesota Medical School.
Chicago: The Year Book Publishers, Inc., 1941. Price:

$3.00.

For the average practhioner who is more or less com-
pletely confused on the use and abuse of the sul-
fonamides this monograph is of real practical value.
The author begins with the historical development and
after discussing the drugs themselves discusses their
use in various diseases. The typography is good and
the material is well arranged. It is recommended to
the geueral practitioner.

MSMS

ESSENTIALS OF GENERAL SURGERY. By Wallace P.
Ritchie, M.D., Clinical Assistant Professor, Department of
Surgery, University of Minnesota Medical School. With 237
illustrations. St. Louis: The C. V. Mosby Company, 1941.

Price: $8.50.

“In general it reflects the attitude and practices of
the Surgical Department of the University of Minne-
sota Medical School.” This 813 page compendium of
surgery provides a basic outline of general surgery and
a review which would save time and energy for the
practicing surgeon. The material is well arranged, the
typography is good and it is recommended to the gen-
eral practitioner for review.

MSMS

DOCTOR COLWELL’S 1942 DAILY LOG. Champaign: Col-
well Publishing Company, 1941. Price: $6.00.

For the doctor who wants a one-volume financial
record this daily log is very simple to use and yet in-
clusive enough to furnish, at any time, complete finan-
cial data of one’s practice. There is space allotted for
almost every need of the general practitioner. The
publishers claim a renewal rate of 90 to 95 per cent
from year to year and renewals of this type of book
should be its greatest recommendation.

1010

Jour. M.S.M.S.

THE DOCTOR’S LIBRARY

MICROBES WHICH HELP OR DESTROY US. By Paul W.
Allen, Ph.D., Professor of Bacteriology and Head of the
Department, University of Tennessee; D. Frank Holtman,
Ph.D., Associate Professor of Bacteriology, University of Ten-
nessee; and Louise Allen McBee, M.S., Formerly Assistant in
Bacteriology, University of Tennessee. St. Louis: The C.

V. Mosby Company, 1941. Price: $3.50.

This was written for your patient who needs to be-
come “microbe conscious.” It is interesting, well or-
ganized, and scientifically correct. The typography is
excellent. It is printed on green tinted paper and well
illustrated. The physician will find it of assistance in
explaining the character of specific diseases to his pa-
tients. It is recommended for the intelligent patient.

MSMS

CARDIAC CLINICS. A Mayo Clinic Monograph. By Fred-
rick A. Willius, B.S., M.D., M.S. in Med., Head of Section
of Cardiology, Mayo Clinic, and Professor of Medicine, Mayo
Foundation for Medical Education and Research, Graduate
School, University of Minnesota, Rochester, Mmn. St. Louis:
The C. V. Mosby Company, 1941. Price: $4.00.

In this monograph Willius after discussing signs and
symptoms of cardiac disease takes up various specific
pathological conditions and discusses them by means
of case reports. This method is indeed enlightening
and aids in fixing the acquired knowledge. It is very
readable but also valuable as a reference book and is
recommended to the general practitioner who has a
special interest in cardiac diseases.

MSMS

OCCUPATIONAL DISEASES. Diagnosis, Medicolegal Aspects,
and Treatment. By Rutherford T. Johnstone, A.B., M.D.,
Director of the Department of Occupational Diseases, Golden
State Hospital, Los Angeles, California ; Formerly Assistant
Professor of Medicine, University of Pittsburgh School of
Medicine. Illustrated. Philadelphia and London : W. B.

Saunders Company, 1941. Price: $7.50.

This very well written and practical reference book
for industrial physicians is of considerable value and
interest to the general practitioner who should be
interested in the relation of health to industry. The
t>'pography is excellent, the plates are well chosen, and
the material is arranged for easy reference.

MSMS

NEW AND NONOFFICIAL REMEDIES, 1941. Containing
descriptions of the articles which stand accepted by the Coun-
cil on Riarmacy and Chemistry of the American Medical
Association on January 1, 1941. Cloth. Price, postpaid, $1.50.
Pp. 691 — LXX. Chicago: American Medical Association, 1941.
“New and Nonofficial Remedies” is the book in which
are described the medicinal preparations found by the
Council on Pharmacy and Chemistry to be acceptable
for the use of physicians. The book is cumulative;
each year there are added the descriptions of products
accepted during the foregoing year. Those taken off
the market or found no longer worthy of continued
acceptance are deleted. The book is at that time also
revised to bring it up to date with the most recent
medical thought. Until recent years the additions and
deletions have about balanced. Recently, however, the
bulk of the book has been increasing and thus year’s
volume represents the largest book of the more than
thirty volumes that have been issued.

This year’s new additions include the new sulfanila-
mide derivative, sulfathiazole, as well as sulfapyridine
sodium ; antipneumococcic rabbit serum of types I, II,
III, V, VII and VIII ; human convalescent measles
serum and human convalescent scarlet fever serum ;
an staphylococcus antitoxin. The field of endocrinology
is represented by the addition of chorionic gonadotropin
(follutein). The addition of shark liver oil reflects
the search for new sources of vitamins A and D caused
by the cutting off of foreign cod liver oil. Other newly
accepted preparations are ampules of camphor, digi-
lanid and magnesium trisilicate.

The most extensive revision is represented by the
rearrangement and amplification of the chapter, “Serums

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1011

THE DOCTOR’S LIBRARY

and Vaccines.” This chapter is now prefaced by a help-
ful index, an innovation in N.N.R. The chapter, “Vita-
mins and Vitamin Preparations for Therapeutic and
Prophylactic Use,” has been revised to keep it abreast
of the newer developments in this field. Here, too,
we find something of an .innovation in the systematic
use of graphic chemical formulas. It is understood
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the book in future editions. Careful perusal will reveal
minor revisions in many parts of the book made in
the interest of greater clarity and in tthe effort to keep
the book thoroughly up to date.

SALUTE TO THE WOMAN'S AUXILIARY

The quiet and modest way in which the Woman’s
Auxiliary works often obscures the value of their con-
tributions both to organized medicine and to the com-
munity at large. This modesty is commendable, but it
is time that The Medical Society recognized, and the
public learned, of the highly effective work being done
by the Woman’s Auxiliary to The Medical Society of
New Jersey. Our women are daily performing tasks
which should be acknowledged by the community. It
would be well if the County Auxiliaries sent to their
local newspapers properly prepared releases telling the
world what they are doing for public welfare.

From the public point of view the most conspicuous
of the good works of the Auxiliary is their donation
of gifts and money to worthy causes. Even a partial
list of the beneficiaries of their efforts will surprise
most of us. Thus, in the past year, the following
agencies and individuals have received gifts, money or
equipment from the Woman’s Auxiliary.

Children’s Homes, Visiting Nurses Association, Brit-
ish War Relief Association, Hospitals, Nurses’ Homes,
Red Cross, Widows and Orphans of Doctors, hospi-
talized ward patients, soldiers in camps in New Jersey,
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perhaps other counties, have established funds to help
worthy student nurses receive their professional educa-
tion. This is philanthropy of the most constructive sort
and it is an investment in human character. The special
Blood Transfusion Fund of Ocean County is a unique
and truly life-saving philanthropic project. The gift of
food, recreational equipment and clothing to both Brit-
ish and American soldiers is a highly practical contri-
bution to National Defense. Through special ques-
tionnaries, the Auxiliary will classify its members with
reference to skills useful in National Defense programs,
particularly in connection with evacuation and sabotage
projects.

Even these imposing contributions, significant as they
are, do not represent the totality of their services. The
Auxiliary is of inestimable value to The iVedical So-
ciety in dozens of other ways, too. They secure medical
speakers and forums for the profession’s public rela-
tions campaign. They promote friendly relationships
among physicians’ families, this work reaching a high-
spot each year when they arrange for the banquet at
the Annual Meeting of The Medical Society of New
Jersey. They keep running the wheels of our Clinical
Conferences by serving as hostesses, registrars and
guides.

The proportion between the size of each County
Medical Society and the much smaller size of the cor-
responding Auxiliary is strange. Perhaps doctors are
at fault in not more fully activating their mothers, sis-
ters and wives to joining the Auxiliary. If so, the fault
should be corrected, for the Auxiliary is an indispen-
sable member of our large New Jersey medical family.
Incidentally, doctors are reminded of the fact that the
Journal contains an Auxiliary section which Auxiliary
members are anxious to read. Make the Journal ac-
cessible to your womenfolk.

We may never have said so before. If so, let it be
said now. We know the full worth of the Auxiliary;
we are grateful to them. — The Journal of the Medical
Society of New Jersey, November, 1^1.

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the medical care of afflicted and crippled children.
However, it cannot pay for bills which it does not re-
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the business office of your hospitals and ascertain if
statements for the services of physicians are being sent,
with the hospital bills, to the Crippled Children Com-
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Jour. M.S.M.S.

1012

INDEX TO VOLUME 40

AUTHORS’ INDEX

Alcorn, Kent, 696
Alpiner, S., 199
Aronstam, Noah E., 355
Ascher, Meyer, 800
Ashley, L. Byron, 43, 287

Bailey, Louis J., 107
Baker, Henry K., 969
Berge, Clarence A., 189
Birch, William G., 535
Bloomfield, J. J., 32
Bogart, Leon M.. 981
Branch, Hira E., 814
Brines, Osborne A., 47, 201, 204
Brooks, Clark D., 43
Brunner, Hans, 363
Brush, Brock, 525

Carter, J. Bailey, 515
Clapper, Muir, 280
Cole, Rufus, 19
Collisi, Harrison S., 965
Cosgrove, S. A., 357

Deakin, Rogers, 440
Dempster, J. H., 705
Downing, John Godwin, 265

Euler, Marjorie, 698
Fandrich, T. S., Ill
Finch, D. L., 199
Fitz, Reginald, 345

Gariepy, L. J., 705

Hanelin, Henry A., 876
Hart, Deryl, 179
Hartzell, John B., 36, 277
Heetderks, Dewey R., 983
Hildreth, R. C, 710
Hill, A. Morgan, 811
Himler, L. E„ 707
Holm, Benton, 988
Hoyt, Donald F., 217
Hubbell, R. J., 710
Humphrey, A. A., 199

Jacoby, Adolph, 435
Jennings, Alpheus F., 606
Jewell, F. C., 272

Keane, William E., 823
Kleinschmidt, Earl E., 458, 971

La Ferte, A. D., 531
Lamberson, Frank A., 603
Lavender, Howard C., 807
Lockwood, Ambrose L., 509, 593
Lofstrom, J. E., 272

McKhann, Charles F., 455
Manning, J. Edward, 201, 204
Marshall, Don, 367
Miller, Hazen L, 609

December, 1941

Mollmann, Arthur H., 882
Moore, V. M., 806
Musser, J. H., 99, 292
Myers, Gordon B., 280

Narotzky, A. S., 287
Neal, Paul A., 32
Nelson, Harry M., Ill
Noth, Paul H, 47

Ormond, John K., 525

Patterson, Ralph M., 271
Payette, Hazen J., 995
Peelen, J. William, 873
Pelouze, P. S., 444
Pierson, Richard N., 691, 884
Priestley, James T., 867

Riecker, Herman H., 208
Robb, J. Milton, 280
Robinson, R. G., 299
Rosenzweig, Saul, 800

Schreiber, Frederic, 603
Schwartz, Louis Adrian, 113
Scully, John C., 979
Selling, Lowell S., 789
Shaffer, Loren W., 529
Sherman, George A., 289
Sichler, H. G., 284
Siddall, Roger S., 612
Smith, Dudley R., 440
Sodeman, W. A., 292
Stalker, Hugh, 105
Steffensen, W. H., 30
Sweany, Henry C., 448

Todd, Oliver E., 191

Van Bree, Raymond S., 197
Van Pernis, Paul A., 806
Webber, Jerome E., 811
Weinberger, Herbert, 289
Willson, J. Robert, 795

Yott, William J., 528

Zlatkin, Louis, 800

CONTRIBUTED PAPERS

A

Acute gangrenous cholecystitis in children. L. Byron
Ashley, M.D., F.A.C.S., and A.S. Narotzky, M.D.,
287

Adjustment of marital problems, The. Lowell S. Sell-
ing, M.D., Ph.D., Dr.P.H., F.A.C.P., 789

Amebiasis with pleuropulmonary complications. George
A. Sherman, M.D., F.A.C.P., and Herbert Wein-
berger, M.D., 289

Anastomosis, End-to-end. Mathematical approach to the
causes of the marginal gangrene. Arthur H. Moll-
mann, M.D., 882

1015

INDEX

Ankle joint, Severe fractures of the. Conservative man-
agement and a presentation of typical cases. How-
ard C. Lavender, M.D., 807

Anoxia, Cerebral, and craniocerebral injuries. Frederic
Schreiber, M.D., 603

Appendicitis — the problem from an educational stand-
point. R. G. Robinson, M.D., 299

Arthritis, a contra-indication for typhoid vaccine fever
therapy. William J. Yott, M.D., 528

B

Blackwater fever. The successful use of sulfanilamide
in the treatment of. Benton Holm, M.D., 988
Bladder, urinary. Sarcoma of the. William E. Keane,
M.D., 823

Blood bank. Experience with the. Osborne A. Brines,
M.D., F.A.C.P., and J. Edward Manning, M.D., 201
Bowel, large, Carinoma of the. Tohn B. Hartzell,
M.D., F.A.C.S., 36

C

Cancer of the cervix. Time wasted. Oliver E. Todd,
B.S., M.D., 191

Carcinoma of the large bowel. John B. Hartzell, M.D.,
F.A.C.S., 36

Carcinoma of the prostate. John K. Ormond, M.D.,
and Brock Brush, M.D., 525
Carcinoma of the stomach — diagnosis and results.

James T. Priestley, M.D., 867
Carcinoma, Primary, of the scrotum. Kent Alcorn,
B.S., M.S., M.D., 696

Cerebral anoxia and craniocerebral injuries. Frederic
Schreiber, M.D., 603

Cervix, Cancer of the. Time wasted. Oliver E. Todd,
B.S., M.D., 191

Changing picture of diabetes, The. Reginald Fitz,
M.D., 345

Cholecystitis, Acute gangrenous, in children. L. Byron
Ashley, M.D., F.A.C.S., and A. S. Narotzky, M.D.,
287

Chronic non-tuberculous lesions of the lungs. J. E.

Lofstrom, M.D., and F. C. Jewell, M.D., 272
Clinico-Pathological Conference. Detroit Receiving
Hospital, 116, 212

Clinico-Pathological Conference. Paul H. Noth, M.S.,
M.D., and Osborne A. Brines, B.S., M.D., 47
Colon, Surgical diseases of the: diagnosis and treat-
ment. Clark D. Brooks, M.D., F.A.C.S., and L.
Byron Ashley, M.D., F.A.C.S., 43
Congenital umbilical hernia. Harry AI. Nelson, M.D.,
and T. S. Fandrich, M.D., 111
Coronary occlusion. Diagnosis of. J. Bailey Carter,
M.D., 515

Coronary vascular heart disease. J. H. Musser, M.D., 99
Craniocerebral injuries. Cerebral anoxia and. Frederic
Schreiber, M.D., 603

Cyanosis of the newborn. Charles F. McKhann, AI.D.,
455

Cyst, Septic branchial, eradication by electrical cauter-
ization. Clarence A. Berge, M.D., 189

D

Dermatitis and eczema — -industrial aspects. John God-
win Downing, M.D., 265

Dermatitis, exfoliative, Sulfathiazole in. Henry K.
Baker, M.D., 969

Development of the plasma bank. Osborne A. Brines,
M.D., F.A.C.P., and J. Edward Planning, M.D., 204
Diabetes, The changing picture of. , Reginald Fitz,
M.D., 345

Diagnosis of coronary occlusion. J. Bailey Carter
M.D., 515

Diethylstilbestrol, Effect of oral administration of, on
menopausal symptoms. J. William Peelen, AI.D .
873

Diverticula, Urethral, and cul-de-sacs. Noah E. Aron-
stam, Al.D., 355

Dyspepsias, The surgical. Ambrose L. Lockwood.
D.S.O., M.C., AI.D., CAL, F.A.C.S., F.R.C.S. (C),

E

Early beginnings of preventive medicine in Alichigan.

Earl E. Kleinschmidt, AI.D., 458
Eczerna, Dermatitis and — industrial aspects- John God-
win Downing, M.D., 265

Effect of oral administration of diethylstilbestrol on
menopausal symptoms. J. William Peelen, AI.D., 873
End-to-end anastomosis. Alathematical approach to the
causes of the marginal gangrene. Arthur H. AIoll-
mann, AI.D., 882

Epilepsy as a traffic hazard. L. E. Himler, AI.D., 707
Eunuchism. Treatment with testosterone propionate.

Hazen L- Aliller, AI.D.. 609
Examination of selectees as a society activity, 991
Experience with the blood bank. Osborne A. Brines,
M.D., F.A.C.P., and J. Edward Alanning, AI.D., 201

Experiences in premarital council in private practice.
Richard N. Pierson, AI.D., 884

F

Factors in maternal health — hospitals and staff groups.
S. A. Cosgrove, AI.D., F.A.C.S., 357

Feminine psychology. Louis Adrian Schwartz, AI.D.,
113

Femur, Fractures of the neck of the. A. D. La Ferte,
AI.D., 531

Fever, Rheumatic. Preventive aspects. Herman H.
Riecker, AI.D., 208

Forensic psychiatry in Alichigan. Ralph AI. Patterson,
M.D., 271

Fractures of long bones, A method for correction of
angulation in- V. AI. Aloore, AI.D., and Paul A.
A/^an Pernis, AI.D., 806

Fractures of the ankle joint. Severe. Conser\ative man-
agement and a presentation of typical cases. How-
ard C. Lavender, AI.D., 807

Fractures of the neck of the femur. A. D. La Ferte,
AI.D., 531

G

Gall-bladder disease — surgical treatment. L. J. Gariepy,
M.D., and J. H. Dempster, AI.D., 705

Genito-urinarj' tract. Radiation therapy in the treat-
ment of malignant disease of the. H. G. Sichler,
M.D., 284

Gonococcal infections. Diagnosis and criterion of cure.
Adolph Jacoby, AI.D., 435

Gonorrhea in the female. Rogers Deakin, AI.D., and
Dudley R. Smith, AI.D., 440

Gonorrhea in the male. P. S. Pelouze, AI.D., 444

Jour. AI.S.AI.S.

1016

INDEX

H

Heart disease, Coronary vascular. J. H. Musser,
M.D., 99

Hernia, Congenital umbilical. Harry M. Nelson, M.D.,
and T. S. Fandrich, M.D., 111

Highlights of twenty-five years of service. The. Mar-
jorie Euler, 698

Hygiene, Industrial. Responsibility of the medical pro-
fession. Paul A. Neal, M.D., and J. J. Bloom-
field, 32

Hypertension, Unusual. A case of ten year’s duration.
Hugh Stalker, M.D., F.A.C.P., 105

Hypothyroidism in children. A review of masked symp-
toms and evaluation of response to thyroid treat-
ment. A. Morgan Hill, M.D., and Jerome E. Web-
ber, M.D., 811

I

Indications for simple and radical mastoid operations.
Hans Brunner, M.D., 363

Industrial hygiene; responsibility of the medical profes-
sion. Paul A. Neal, M.D., and J. J. Bloomfield, 32

Injuries, Self-inflicted, in civil practice. Deryl Hart,
M.D., 179

Intestinal suction drainage in facilitating one-stage re
section of the right colon. John B. Hartzell,
M.D., 277

Intravenous or retrograde pyelography? R. J. Hubbell,
M.D., and R. C. Hildreth, M.D., 710

L

Labor, Uterine inertia in the first stage of. Roger S.
Siddall, M.D., 612

Lungs, Chronic non-tuberculosis lesions of the. J. E.
Lofstrom, M.D., and F. C. Jewell, M.D., 272.

M

Malignant disease of the genito-urinary tract. Radiation
therapy in the treatment ©f. H. G. Sichler, M.D.,
284

Marital problems. The adjustment of. Lowell S. Sell-
ing, M.D., Ph.D., Dr.P.H., F.A.C.P., 789
Marriage after forty. Harrison S. Collisi, M.D.,
F.A.C.S., 965

Massive arsenotherapy in early syphilis. Loren W-
Shaffer, M.D., 529

Mastoid operations, simple and radical. Indications for.
Hans Brunner, M.D., 363

Maternal health. Factors in. Hospitals and staff groups.

S. A. Cosgrove, M.D., F.A.C.S., 357
Medical societies and medical progress. Rufus Cole,
M.D., 19

Menopausal symptoms. Effect of oral administration of
diethylstilbestrol on. J. William Peelen, M.D., 873
Method for correction of angulation in fractures of
long bones. V. M. Moore, M.D., and Paul A.
Van Pernis, M.D., 806

Modern treatment of traumatic shock. The. Henry A.
Hanelin, M.D., 876

Moniliasis — sulfapyridine treatment. Raymond S. Van
Bree, M.D., 197

Movement for the registration of vital statistics. Earl
E. Kleinschmidt, M.D., Dr.P.H., 971
Muscular dystrophy. Progressive pseudohypertrophic.
A new regime of treatment. Hira E. Branch,
M.D., 814

December, 1941

N

Nose, The physiology of the. Dewey R. Heetderks,
M.D., 983

O

Ophthalmia, S^pathetic. Don Marshall, M.D., 367
Orbital complications. Sinusitis. W. H. Steffensen,
M.D., F.A.C.S., 30

P

Pain, Presacral resection for the relief of. John C.
Scully, B.S., M.D., 979

Parenthood, Planned. Its contribution to national pre-
paredness. Richard N. Pierson, M.D., 691
Physiology of the nose. The. Dewey R. Heetderks,
M.D., 983

Pituitrin in postpartum hemorrhage. Transabdominal
intra-uterine injection. Donald F. Hoyt, M.D., 217
Planned parenthood. Its contribution to national pre-
paredness. Richard N. Pierson, M.D., 691
Plasma bank, Development of the. Osborne A. Brines,
M.D., F.A.C.P., and J. Edward Manning, M.D., 204
Pneumococcus, Type III, meningitis — recovery follow-
ing sulfathiazole. Gordon B. Myers, M.D., J. Mil-
ton Robb, M.D., and Muir Clapper, M.D., 280
Pneumonia. Qinical diagnosis. Alpheus F. Jennings,
M.D., 606

Postpartum hemorrhage, Pituitrin in. Transabdominal
intra-uterine injection. Donald F. Hoyt, M.D., 217
Postpartum sterilization. William G. Birch, M.D., 535
Pregnancy, Uterine fibroids complicating. J. Robert
Willson, M.D., 795

Pregnancy, Vitamin and mineral requirements in. J. H.

Musser, AI.D., and W. A. Sodeman, M.D., 292
Premarital council. Experiences in, in private practice.

Richard N. Pierson, M.D., 884
Pre-operative preparation of the patient. Ambrose L.
Lockwood, D.S.O., M.C., M.D., C.M., F.A.C.S.,
F.R.C.S. (C), 509

Presacral resection for the relief of pain. John C.
Scully, B.S., M.D., 979

Preventive medicine in Michigan, Early beginnings of.

Earl E. Kleinschmidt, M.D., 458
Primary carcinoma of the scrotum. Kent Alcorn, B.S.,
M.S., M.D., 696

Primary tuberculous infection in the adult. Henry C.
Sweany, M.D., 448

Progressive pseudohypertrophic muscular dystrophy. A
new regime of treatment. Hira E. Branch,

M.D., 814

Prostate, Carcinoma of the. John K. Ormond, M.D.,
and Brock Brush, M.D., 525
Pseudohypertrophic muscular dystrophy. Progressive. A
new regime of treatment. H.ra E. Branch,

M.D., 814

Psychiatry, Forensic, in Michigan. Ralph M. Patterson,
M.D., 271

Psychology, Feminine. Louis Adrian Schwartz, M.D.,
113

Pyelography, Intravenous or retrograde? R. J. Hub-
bell, M.D., and R. C. Hildreth, M.D., 710

R

Radiation therapy, in the treatment of malignant disease
of the genito-urinary tract. H. G. Sichler, M.D.,
284

Relationship of the roentgenologist to the physician and
surgeon. The. Leon ^I. Bogart, M.D., 981

1017

INDEX

Rheumatic fever. Preventive aspects. Herman H.
Riecker, M.D., 208

Roentgenologist, The relationship of the, to the physi-
cian and surgeon. Leon M. Bogart, M.D., 981

S

Sarcoma of the urinary bladder. William E. Keane,
M.D., 823

Scrotum, Primary carcinoma of the. Kent Alcorn,
B.S., M.S., M.D., 696

Self-inflicted injuries in civil practice. Deryl Hart,
M.D., 179

Septic branchial cyst. Eradication by electrical cauteri-
zation. Clarence A. Berge, M.D., 189

Service, The highlights of twenty-five years of. Mar-
jorie Euler, 698

Severe fractures of the ankle joint. Conservative man-
agement and a presentation of typical cases. How-
ard C. Lavender, M.D., 807

Shock, traumatic. The modern treatment of. Henry
A. Hanelin, M.D., 876

Sinusitis — orbital complications. W. H. StefTensen,
M.D., F.A.C.S., 30

Staphylococcus albus bacteremia secondary to a car-
buncle of the nose, Sulfamethylthiazol in. D. L.
Finch, M.D., S. Alpiner, M.D., and A. A. Humph-
rey, M.D., 199

Sterilization, Postpartum. William G. Birch, M.D., 535

Stomach, Carcinoma of the. Diagnosis and results.
James T. Priestley, M.D., 867

Successful use of sulfanilamide in the treatment of
blackwater fever. The. Benton Holm, M.D., 988

Suction drainage. Intestinal, facilitating one-stage resec-
tion of the right colon. John B. Hartzell, M.D., 277

Sulfamethylthiazol in Staphylococcus albus bacteremia,
secondary to a carbuncle of the nose. D. L. Finch,
M.D., S. Alpiner, M.D., and A. A. Humphrey,
M.D., 199

Sulfanilamide, The successful use of, in the treatment
of blackwater fever. Benton Holm, M.D., 988

Sulfathiazole in exfoliative dermatitis. Henry K.
Baker, M.D., 969

Surgical diseases of the colon. Diagnosis and treatment.
Clark D. Brooks, AI.D., F.A.C.S,, and L. Byron
Ashley, M.D., F.A.C.S., 43

Surgical dyspepsias. The. Ambrose L. Lockwood,
D.S.O., M.C., M.D., CM., F.A.C.S., F.R.C.S.
(C), 593

Sympathetic ophthalmia. Don Marshall, M.D., 367

Syphilis, early. Massive arsenotherapy in. Loren W.
Shaffer, M.D., 529

T

Testis, The undescended. Louis J. Bailey, M.D., M.Sc.
(Med.), F.A.C.P., 107

Testosterone propionate, treatment with. Eunuchism.
Hazen L. Miller, M.D., 609

Tongue, Xanthoma of the. Frank A. Lamberson,
M.D., 603

Traffic hazard. Epilepsy as a. L. E. Himler, M.D., 707
Tuberculous infection. Primary, in the adult. Henry
C. Sweany, M.D., 448

Type III pneumococcus meningitis. Recovery following
sulfathiazole. Gordon B. Myers, M.D., J. Milton
Robb, M.D., and Muir Clapper, M.D., 280

Typhoid vaccine fever therapy, a contra-indication for.
Arthritis. William J. Yott, M. D., 528

U J

Undescended testis. The. Louis J. Bailey, M.D., M.Sc 1

(Med.), F.A.C.P., 107 1

Unusual hypertension. A case of ten years’ duration. i
Hugh Stalker, M.D., F.A.C.P., 105

Urethral diverticula and cul-de-sacs. Noah E. Aron- ‘

stam, M.D., 355 ^

Urinary bladder. Sarcoma of the. William E. Keane,
M.D., 823

Uterine fibroids complicating pregnancy. J. Robert
Willson, M.D., 795

Uterine inertia in the first stage of labor. Roger S.
Siddall, M.D., 612

V

Varicose veins. Allergic reactions in injection treatment.
Saul Rosenzweig, M.D., Aleyer Ascher, ^I.D., and
Louis Zlatkin, M.D., 800

Vital statistics. Movement for the registration of. Earl
E. Kleinschmidt, M.D., Dr.P.H., 971

Vitamin and mineral requirements in pregnancy. J. H.
Musser, M.D., and W. A. Sodeman, ^I.D., 292

X

Xanthoma of the tongue- Frank A. Lamberson, M.D.,
603

DEPARTMENT INDEX
Business Side of Medicine

Business side of medicine in boom times. The. Allison
E. Skaggs and Henry C. Black, 741

Communications

Bennett, Dorothy A., 662
Doran, Frank, 1006
Jones, Harold W., 312
Lewis, S. M., 1006
Richards, R. Milton, 1006

County and Personal Activities

County and Personal Activities, 65, 149, 231, 313, 399,
481, 555, 655, 748, 926, 1004

Doctor’s Library

Allen, Paul W., Holtman, D. Frank, and McBee,
Louise Allen : Microbes which help or destro}- us,

1011

American Medical Association : Annual reprints of

the reports of the Council on Pharmacy and Chem-
istry, 838

American Medical Association, Council on Pharmacj’
and Chemistry: New and nonofiicial remedies,

932, 1011

Andes, Jerome E., and Eiaton, A. G. : Synopsis of ap- y

plied pathological chemistry, 932 ^

Baily, Hamilton : Emergency surgery, 486 '

Bard, Philip (editor) : Macleod’s physiolog>’ in modem
medicine, 563

1018

JouK. M.S.M.S.

INDEX

Blond, Kasper : Hemorrhoids and their treatment ;

the varicose S3mdrome of the rectum, 71
Boyd, William : An introduction to medical science,

662

Bridges, Milton Arlanden ; Dietetics for the clinician,
563

Brinton, Denis : Cerebrospinal fever, 836

Brown, Lawrason ; The story of clinical pulmonary
tuberculosis, 562

Browning, Ethel ; Modem drugs in general practice,
406

Burnet, F. M. : Biological aspects of infectious di-

sease, 317

Qeckley, Hervey : The mask of sanity, 405
Clendening, Logan : Methods of treatment, 157

Cohen, Milton B. : A manual of allergy, 561

Cohen, Francis E., and Odegard, Ethel J. : Principles

of microbiology, 1010

Collier, Howard E. : Outlines of industrial medical

practice, 836

Coltman, Gavle ; Textbook for male practical nurses,
405

Colwell’s 1942 daily log, 1010

Cooper, Lenna F., Barber, Edith M., and Mitchell,
Helen S. : Nutrition in health and disease, 1010

Crampton, C. Ward : Start today, your guide to physi-

cal fitness, 757

Crossen, Harry Sturgeon : Foreign bodies left in the

abdomen, 158

Dick, George F. (editor) : The 1940 year book of

general medicine, 71

Dickinson, Robert Laton : Techniques of conception

control, 406

Dorland, W. A. Newman : The American illustrated

medical dictionary, 836

Eddy, Walter H. : The avitaminoses, 486

Eliason, Eldridge L. : First aid in emergencies, 486

Fairbrother, R. W. ; A textbook of bacteriology, 932

Feder, J. M. : The essentials of applied medical labora-
tory technic, 486

Geckeler, Edwin O. : Fractures and dislocations for

practitioners, 72

Geiger, J. C. (editor) : The 1941 year book of public

health, 1010

Gerling, C. J. : The complete weight reducer, 932

Gifford, Sanford R. : A textbook of ophthalmology,

561

Goldhamer, Karl : X-ray therapy of chronic arthritis

(foreword by Harold Swanberg), 757
Graybiel, Ashton ; Electro-cardiography in practice,
317

Greisheimer, Esther M. : Physiology and anatomy, 72

Griffith, J. P. Crozer, and Mitchell, A. Graeme : Text-

book of pediatrics, 561

Grollman, Arthur : Essentials of endocrinology, 661

Harper Hospital, Dietetics Department : Diet manual,

236

Harris, Harold J. : Brucellosis, 562

Harris, Seale : Clinical pellagra, 157

Helpart, Bela; Necropsy, 837

Herrmann, George R. : Synopsis of diseases of the

heart and arteries, 661

Hess, Julius H., and Lundeen, Evelyn C. : The pre-

mature infant, 1010

December, 1941

Hewitt, Richard M., et al. : Collected papers of the

Mayo Qinic and the Ma>^o Foundation, 755
Holmes, George W., and Ruggles, Howard E. : Roent-
gen interpretation, 486

Johnstone, Rutherford T. : Occupational diseases, 1011

Joslin, Elliott P. : A diabetic manual, 405

Karsner, Howard T. ; and Hooker, Sanford B. (edi-
tors) : The 1940 year book of pathology and im-

munology, 158

Kessler, Henry H. : Accidental injuries, 661

Kolmer, John A., and Tuft, Louis: Clinical immun-

ology, biotherapy and chemotherapy, 931
Kracke, Roy R. (editor) : A textbook of clinical

pathology, 236

Kraines, Samuel Henry : The therapy of neuroses and

psychoses, 406

Krusen, Frank H. : Physical medicine, 561

Ladd, William E., and Gross, Robert E. : Abdominal

surgery of infancy and childhood, 837
Levinson, Charles A. : Food, teeth and larceny, 317

Lewin, Philip : Infantile paralysis, 755

Lewin, Philip ; The foot and ankle, 1010
Light, Richard Upjohn; Focus on Africa, 486
Loewenberg, Samuel A. : Medical diagnosis and S}’mp-

tomatology, 563

McKibbin-Harper, Mary : The doctor takes a holi-

day, 562

May, Charles H. ; Manual of the diseases of the eye,
837

Meakins, Jonathan Campbell; The practice of medi-
cine, 71

Modern serological tests for syphilis, 662

Newer chemotherapy of venereal diseases, 662
Nygaard, Kaare K. : Hemorrhagic diseases, 405

Painter, Charles F. (editor) : The 1940 year book

of industrial and orthopedic surgery, 158
Popenoe, Paul : Modem marriage, 837

Portis, Sidney A. (editor) ; Disease of the digestive
system, 236

Reiner, Miriam ; Manual of clinical chemistry, 405

Ritchie, Wallace P. ; Essentials of general surgery,

1010

Rosenberg, Max M. : It is your life, 236

Smith, Anne Marie : Play for convalescent children,

757

Smith, Frederick C. . Proctology for the general prac-
titioner, 486

Spink, Wesley W. : Sulfanilamide and related com-

pounds in general practice, 1010
Sutton, Richard L., and Sutton, Richard L., Jr.: An

introduction to dermatology', 486

Taber, Clarence Wilbur: Taber’s cyclopedic medical

dictionary, 71

Thewlis, Melford : The care of the aged, 931

Thorndike, Augustus, Jr.; A manual of bandaging,
strapping, and splinting, 1010
Tobias, Norman: Essentials of dermatology, 836

Top, Franklin H. : Handbook of communicable dis-

eases, 931

Vanderbilt University. A symposium ; Infantile paraly-
sis, 757

1019

INDEX

Vaughan, Warren T. : Strange malady, 317

Watson-Jones, R. : Fractures and other bone and

joint injuries, 661

Wilder, Russell M. : A primer for diabetic patients,

755

Willius, Frederick A.: Cardiac clinics, 1011

Willius, Frederick A., and Keys, Thomas E. : Cardiac

classics, 563

Zondek, Bernard : Clinical and experimental investiga-

tions on the genital functions and their hormonal
regulation, 755 ^

Editorial

AMA needs a new charter. The, 388
“Advanced first-aid for civilian defense,” 1000
An error corrected, 826
Annual county secretaries’ conference, 1000

Appreciation to Michigan Legislature and the governor,

1000

Back to the seventeenth century by order of the Su-
preme Court, 121

Best yet. The, 826

Cancer in Michigan, 303

Council elections, 122

Detroit, a major medical center, 53

Discussion conferences, 540

Doctor and safety, The, 466

Doctor comes second. The, 892

Don’t tell the world, 304

Emergency needs for narcotics, 1001

General practitioner, 220

Great meeting. A, 618

His father’s footsteps, 714

Hospital, Dr.? 54

In these hands, 890

Keeping out of trouble, 1000

Mad dogs, 466

Mature judgment needed, 618

Medical preparedness in Michigan, 994

Merry Christmas, 995

Michigan Medical Service, 826

Muskegon honors George L. Le Fevre, 388

Postgraduate courses for the upper peninsula, 893

Read and write, '303

Readers’ service, 893

Refuge from ragweed, 541

Relief for the doctor, 121

Report rheumatic fever, 220

State of Washington solves its state-medicine threat.
The, 1000

Vacations, 540

You have the facts, 994

Your wish has come true, 714

Experimental Procedures

Pituitrin in postpartum hemorrhage. Transabdominal
intra-uterine injection. Donald F. Hoyt, M.D., 217

Half a Century Ago

Dignity of the profession. Lyman W. Bliss, M.D., 332
Diphtheria — What shall we do with it? W. C. Hunt-
ington, M.D., 502

Four months’ work in laparotomy. J. H. Carstens,
M.D., 772

Gall stones — a newer plan of treatment. J. R. W'illiams,
M.D., 676

La grippe. B. B. Godfrey, M.D., 948

Need for a better study of diseases of the skin. The.
W. F. Breakey, M. D., 852

One day with the village doctor. Charles S. Cope,
AI.D., 580

Phthisis. Heneage Gibbes, M.D., 420

In Memoriam

Adams, John F., 304
Bates, La Motte F., 397
Belote, John F., 304
Bevington, Harry G., 831
Bolender, J. E., 304
Bullock, Earl S., 560
Burleson, Arthur H., 304
Cameron, Don Bruce, 304
Campbell, A. Milton, 831
Diamond, Francis J., 658
Dick, Kenneth W ., 304
Edmunds, Charles W., 479
Frank, Maxwell Nathaniel, 479
Forbes, Edwin B., 479
Gustin, J. William, 753
Hafford, George Clinton, 397
Haviland, James J., 397
Heffron, Charles H., 397
Henry, Thomas Jefferson, 304
Hewitt, Herbert W., 70
Hoff, Edwin C., 70
Huegli, Albert G., 398
Huizinga, J. G., 155, 304
Hungerford, P. R., 479
Husband, Francis H., 398
Laverty, L. F., 1007
Leitch, Arthur E., 70
MaePherson, Alexander H., 304
Morton, Moses Emmett, 70
Munro, Frederick W., 1007
Owen, Arthur E., 1007
Petrie, W. Paul, 479
Riley, William H., 831
Rockwell, Alvin H., 658
Rosenblum, Herman G., 70
Royer, William A., 398
Sackrider, George P., 398
Sanderson, Hermon Harvey, 753
Sawicki, Bruno J., 70
Schram, John A., 831
Seybold, George A., 831
Smith, Eugene, Jr., 479
Smith, G. Reginald, 753
Stewart, L. H., 480
Valade, Cyril K., 398
Walker, Claude W., 753

1020

Jour. M.S.M.S.

INDEX

West, Arthur E., 480
Wilkinson, Chester Ambrose, 70
Wilson, Ehvood D., 658

Michigan’s Department of Health

1940 state’s safest }ear for babies? 64

1941 births set new record, 1003
100,000 births in 1941? 653
100,000 Kahn’s a month, 553
Cancer program expanded, 829
Communicable disease comparison, 473
Communicable disease reports, 654
Decline of contagion, 64

Defense industries spend $350,000 for health, 926

Diphtheria in two schools, 926

Diphtheria outbreaks in August, 830

“Flu” not reported, 148

Firearms accidents, 64

Free sulfathiazole, 394

Haj'fever immunity treatments, 474

Health of defense workers, 926

Health units appraised, 230

Kahn tests set new record, 473

Kellogg grant aids virus research, 1003

Less measles in June, 654

Lobar pneimionia less, 230

Malaria in Michigan, 746

Marked decrease in smallpox, 148

^larriages increase 23 per cent, 474

Maternal mortality at new low, 474

Measles cases double, 148

Measles, 50,000 cases of, 473

Measles increase, 64

Michigan record better than nation, 829

Midwinter joint meeting, 148

More births, 64

Near epidemic of measles, 308

New acting deputy commissioner, 394

New Bureau of Tuberculosis, 230

New health units, 653

New high record in births, 308

New low death rates, 393

New pneumonia serum available, 148

New sanatorium consultant, 830

New water supplv prompts dental survev in Escanada,
1003

Not enough public health nurses, 553

Obstetrics course in January, 925

Obstetrics studies open to four, 654

Ph}'sicians can register births of 3ears ago, 926

Pneumonia deaths drop, 393

Polio cases below average, 829

Poliomyelitis low in Juh", 747

Record low infant death rate, 308

Rocky Mountain spotted fever, 552

Safe water, 474

Saginaw survey finds eleven new cases, 474

September infantile parah*sis under normal, 926

Shiawassee, 148

Shiawassee sixty-third, 64

Sixty-five county health units, 7-16

Sixty-seven polio cases in November, 64

December, 1941

Smallpox at Port Huron, 654
Smallpox cases increase, 747

Smallpox outbreak exposes induction center, 1003
State money' needed, 148
Syphilis tests reach new high, 747
Whooping cough communicable disease No. 1, 926
Whooping cough highest in five years, 1003
\\ ill there be any poliomyelitis in ^Michigan this year ?
S. D. Kramer, M.D., 550

Michigan State Medical Society

Committee reports, 637

County secretaries’ conference, 145

Delegates to M.S.^I.S. House of Delegates, 470

^lid-winter meeting of the Council, 134

Preliminary program, 623

Proceedings, 1941 meeting, 894

Program. 717

Roster, 371, 472, 559

Sessions of House of Delegates, 76th annual meet-
ing, 545

Miscellaneous

Coroner action required in all cases not seen by physi-
■ cian during thirty-six hours preceding death, 999
Examination of selectees as a society activity, 991
^Medical preparedness committees, 73
Medical preparedness in Michigan, 131
Medical profession and selective service, The. 221, 258
Michigan hospitals and medical payments, 123
Michigan Medical Service, 55, 129, 223, 250, 328, 416,
496, 576, 672, 768, $48, 946

Neuro-psychiatric Institute of Hartford Retreat — An-
nouncement, 7-44
Postgraduate program, 740
Program for graduates in medicine, 132, 222
Remission of dues of members in service, 131
Short sketch of Heneage Gibbes, 678
What about Grand Rapids? 715

You are going to pay more taxes. Hazen T. Pavette,
LL.B., 995

President’s Page

Afflicted — Crippled children, 539

Annual meeting, and farewell, The, 713

iMedical rehabilitation of rejected draftees, 120

Medicine marches forward, 889

N.Y.A. health program, 52

One examination for selectees, 302

Postgraduate education in Michigan, 619

Season’s greetings. The, 993

Success, and thanks, -467

To the future, 825

What value membership? 387

Your responsibility to your legislator, 219

Woman’s Auxiliary

Woman’s Auxiliary, 62, 1-16, 228, 309, 395, 475, 554, 92d

You and Your Business

1941 convention in Grand Rapids, 61
-Ambiguous law, -An, 226

-Annual report of Legislative Committee, 1940-1941,
547

1021

INDEX

Association of physicians and cultists, 306
Benefits of membership, 306

Brown-Wagner-George Hospital Construction Bill, The,
468

Call it “The Beaumont Bridge,” 305
Damage may result from the act, 468
“Every eligible physician,” 58

Honorary and associate membership for laymen, 58
In Michigan, it’s two years, 305

Instalment credit regulations not to affect loans for
medical and hospital expenses, 920
Intangibles tax and accounts receivable, 57
“Invite them to join,” 923

Is the business boom affecting your collections? 924
Keeping complete written records. Leo M. Ford, J.D.,
59

Law on obstetrical engagements. The, 226
Laws affecting doctors, 58

Legislation for crippled and afflicted children, 390
Liability of a city-employed physician, 58
Liability of physicians in military service, 227
M.S.M.S. dues not raised, 133
“Malpractice fever,” 392

Medical welfare in Michigan — Results of survey, 922
Medicine out of the air, 828
Membership increase, 390
Membership marches upward, 828

Michigan hospitals and medical payments plan, 226,
305, 922

Michigan’s intangibles tax, 133
Military membership, 392
National conference on medical service, 133
Not a privileged communication, 133
NYA health examinations discontinued, 920
One examination for draftees, 920

Physicians may select hospitals for afflicted children,
828

Placement bureau, 227, 828
Privileged communications, 58, 922
Rehabilitation of rejected draftees, 920
Right and wrong way. The, 57
Roster number, 305
Thanks, 828

Use the title “M.D.,” 61

Workmen’s compensation law on choice of healer, 390
Your income tax, 923

1022

Tour. M.S.M.S.